Silver Oaks

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not seek timely medical care for resident

On August 13, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Dietary Supervisor, Francis Macahilas and explained the purpose of the visit. Regarding the allegation, staff did seek timely medical care for resident, according to the reporting party, the facility failed to call the after-hour supportive care service during the weekend to report Resident 1's (R1's) symptoms, but rather faxed 3 reports to the physician's office (fax reports were not provided when requested by LPA) that is only open during regular business hours. In addition, the reporting party indicated on June 30, 2025, chest x-rays were ordered for R1, however on July 1, 2025, it was indicated by the third party radiology company that on 6/30/25 in the evening, the technician went out to do the x-ray but was told by facility staff that there is no resident by R1's name so the technician left and R1 didn't get histhe state’s words, verbatim · CDSS document, Aug 13, 2025 · control 14-AS-20250703082904

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mismanaging resident's medication

On March 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Joshua Lambengco explained the purpose of the visit. Regarding the allegation, staff are mismanaging resident's medication, according to the reporting party, it was observed that there were pills under Resident 1's (R1's) bed that was either not swallowed or was spit out. In addition, photos were provided by reporting party. During the investigation, LPA interviewed the administrator, staff and reviewed photos that were provided. Based on the photo provided, LPA did observe medication on the floor in R1's room. According to the administrator, R1 is no longer a resident at the facility. LPA was unable to count R1's medication or interview R1 during the complaint visit. According to the administrator and staff interviewed, R1 has a behavior where he/she will hide the medication in his/her mouth while stafthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 14-AS-20241226105243

Allegation investigated: Staff did not re-order residents medication timely causing the resident to have seizures

On December 26, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit. Regarding the allegation, staff did not re-order residents medication timely causing the resident to have seizures, according to the reporting party, on 12/19/24, Resident 1 (R1) had a seizure in the morning and another seizure at 1pm. In addition, the reporting party stated, the facility reordered lorazepam earlier in the week for R1 which is supposed to be given three times a day for seizure prevention, however it was stated that the facility did not notify the provider when they ran out of lorazepam and R1 received the last dose of lorazepam in the morning on 12/18/24 which caused R1 to have multiple seizures 24 hours later. During the investigation, LPA reviewed R1’s physician’s report, medication list, and medication administrative records (MAR). Based on the medication list and phthe state’s words, verbatim · CDSS document, Dec 26, 2024 · control 14-AS-20241219154758

Allegation investigated: -Staff do not ensure residents have incontinence supplies -Staff did not follow protocals to prevent the spread of COVID -Staff do not meet resident needs

On October 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit. Regarding the allegation, staff do not ensure residents have incontinence supplies, according to the reporting party, facility does not provide enough incontinence supplies to residents. During the investigation, LPA observed the facility's supplies closet and observed a sufficient amount of incontinence supplies. In addition, according to the administrator and staff interviewed, the Clinical Director and Med-techs conduct an audit of the supply room every week and puts an order in to to get supplies delivered once a week to the facility. Regarding the allegation, staff did not follow protocols to prevent the spread of COVID, according to the reporting party, there was a COVID outbreak in September and the facility did not follow county protocols. During the investigation, LPA interviewethe state’s words, verbatim · CDSS document, Oct 22, 2024 · control 14-AS-20241016092524

Allegation investigated: - Facility staff did not dispense medications as prescribed

On 09/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegation received. LPA met with the administrator Joshua Lambengo via facetime and explained the purpose of today's visit. During the course of the investigation LPA conducted interviews, reviewed documentation, and photographs related to the allegation. Per interviews conducted it was confirmed that the pharmacy only filled and sent the prescription antibiotic to the facility one time. There wasn't more than one order of the prescription sent to the facility per the pharmacy. Nurses made observations on three dates that the medication was not being dispensed as prescribed. This poses an immediate health and safety risk to residents in care. Based on these items the allegation is substantiated. Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation isthe state’s words, verbatim · CDSS document, Sep 20, 2024 · control 14-AS-20240718122157

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not mandated reporter certified

On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Joshua Lambengco and Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit. Regarding the allegation of Staff are not mandated reporter certified, Responsible party (RP) stated that a full-time staff doesn’t have mandated reporter training. RP stated that the staff is not reporting things (residents that smell, hitting each other, coughing or thirsty) that happen around the facility to licensing. RP stated that the staff does tell other staff about what he/she sees but that is it. LPA interviewed Resident Care Coordinator (RCC) Bernadette Kang and she mentioned that everyone needs to sign the SOC341A (Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders) for Mandatory Reporting upon hiring. LPA interviewed four staff members and it was mentioned that when an incident happthe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 14-AS-20240408142422

Allegation investigated: Resident sustained unexplained bruises while in care.

On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit. Regarding the allegation of Resident sustained unexplained bruises while in care. Reporting party (RP) states that staff blame RP for the bruises, but RP wants the facility to investigate if the bruising is caused by facility staff. LPA interviewed two staff members who provide care for R1, and both confirmed that resident is combative and hits them when provided care. LPA also interviewed one witness (W1) and confirmed that R1 was being roughly handled by a visitor and but not by staff. R1s doctor (PCP) was also interviewed, and it was mentioned that the bruises can be normal and related to aging as well as other medical problems. It may also be due to non-benign causes. There were no bruises on the face, chest, bottom, or other areas that would highly raise concern for abusethe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 14-AS-20240105152428

Allegation investigated: Staff did not safeguard residents personal belongings Staff are not meeting residents needs

On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit. Regarding the allegation that staff did not safeguard residents’ personal belongings, Reporting party (RP) stated that there have been items that have come up missing in resident’s room. LPA attempted to interview eleven responsible parties. Five responsible parties mentioned that they don’t have any issue with regards to missing belongings of the residents. F1 mentioned that there hasn’t been any instance where they had problems with items being lost. F4 said that some things tend to get lost but is later found. The other responsible parties weren’t available for interview. F5 also mentioned a tv remote being lost but was found the same day. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 14-AS-20240305082355

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not providing resident's authorized representative with a refund

On 1/11/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator, Ollie Vance and Resident Care Coordinator Shayla Brewster and explained the purpose of the visit. Regarding the allegation of Staff are not providing resident's authorized representative with a refund, reporting party (RP) stated that he/she has sent emails and made multiple calls to the finance person (S1) and there is no response if there is a refund. LPA interviewed RP and confirmed that there has been emails sent to S1 and that no response was provided. LPA also interviewed the Administrator and it was mentioned that S1 was on vacation during this time. Administrator wasn't aware of the email but was reviewing the refund around this time. Facility had to review the initial refund as RP overpaid by a month. Facility wanted to give the correct amount. A check has already been sent out. Therefore, based on the interviews conducted, files reviewedthe state’s words, verbatim · CDSS document, Jan 11, 2024 · control 14-AS-20240104100544

Allegation investigated: Staff did not ensure that changes in a resident's condition were brought to the attention of a physician.

On 12/29/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator, Ollie Vance and Resident Care Coordinator Shayla Brewster and explained the purpose of the visit. Regarding the allegation of staff did not ensure that changes in a resident's condition were brought to the attention of a physician, RP stated that he/she is concerned because when he/she is at this facility, RP observes an older resident who seems to be in pain and in distress. During the investigation, LPA reviewed records that show correspondence between resident care coordinator and admininstrator and physician. Records also show how physician addressed the adjustment of medication for the resident. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report was discussed with Admithe state’s words, verbatim · CDSS document, Dec 29, 2023 · control 14-AS-20231222083757

Allegation investigated: Staff are unable to communicate with residents due to a language barrier

On 11/06/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator Ollie Vance & Resident Care Coordinator Shayla Brewster. LPA explained the purpose of the visit. Regarding the allegation that Staff are unable to communicate with residents due to a language barrier, reporting party (RP) stated the facility has been hiring caregivers that only speak Spanish and the residents can’t communicate their needs with them. LPA observed during breakfast and activity time that Spanish speaking caregivers try to communicate with residents. Caregivers that were observed try to do basic sign language. They asked residents if they wanted some water or try to show them where they can sit during the start of the activity. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 6, 2023 · control 14-AS-20230920091013

Allegation investigated: Staff speaks inappropriately to residents in care.

Amended Report On 10/25/2023, Licensing Program Analyst (LPA) Grace Donato an unannounced 10-day complaint inspection.. LPA met with Resident Care Director, Shayla Brewster and explained the purpose of the visit. Regarding the allegation that staff speaks inappropriately to residents. Reporting party (RP) mentioned that residents are spoken too with inapproriate language by a staff member (S1). Based on staff interviews, four out of four mentioned that they haven't heard anything or seen anything where S1 was talking to a resident inappropriately, they also cannot confirm that these incidents happened. S1 was also interviewed and could't recall any incident where a resident was spoken to inapproriately. LPA also interviewed two residents. One mentioned that they haven't heard anything about S1 not helping or shouting at residents. Another mentioned that S1 always help with whatever they need or request. Both residents like living here and feels that they are well taken care of. Based othe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 14-AS-20231020143805

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff mishandled a resident's medications while in care Staff are not properly administering a resident's medications

On 10/6/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Administrator, Ollie Vance & Resident Care Coordinator Shayla Brewster. LPA explained the purpose of the visit. Regarding the allegation that staff mishandled a resident's medications while in care and staff are not properly administering a resident's medications, reporting party (RP) the facility's inability to accurately administer medications and their inability to refill medications in a timely manner is putting this pt at risk for further seizures and risk for injuries. During one of RPs visit, a supply that was dispensed on 08/10 should have only lasted through 08/31, but on 08/31, at least half of the bottle of Lacosamide solution was remaining. Based on the amount of medication remaining, RP suspected that R1 has only been getting half of the prescribed dose. R1 also has lorazepam routinely for seizure prevention. Staff reported thathe state’s words, verbatim · CDSS document, Oct 6, 2023 · control 14-AS-20230901160215

Allegation investigated: Due to staff negligence, resident had multiple witnessed falls causing injury Staff did not feed/give drink to the resident Staff did not allow resident to have a visitor

On 09/01/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Resident Care Coordinator Shayla Brewster and Administrator Ollie Vance followed after. LPA explained the purpose of the visit. Regarding the allegation that staff did not feed/give drink to the resident (R1), according to the reporting party, they have a video showing staff being negligent to the resident. The food was placed in front of the resident and staff did not assist on feeding. LPA interviewed six staff members. Record reviews and observations were also done. Six out of six staff members mentioned that residents do have a schedule for eating, three meals a day including three snacks in between. Asked what if residents don’t want to eat, staff tries to ask 3 times and would offer Ensure in the end to make sure residents are nourished. There are also 2 hydrations stations in the facility. Residents are offered and encouraged everythe state’s words, verbatim · CDSS document, Sep 1, 2023 · control 14-AS-20230620110243

Allegation investigated: Staff do not ensure that residents' bathing needs are met while in care. Facility is dirty. Staff are not ensuring that resident's are administered medication(s) according to physician's instructions.

This is an amended report. On 09/01/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced 10-day complaint inspection. LPA met with Resident Care Coordinator Shayla Brewster and Administrator Ollie Vance followed. LPA explained the purpose of the visit. Regarding the allegation that staff do not ensure that residents' bathing needs are met while in care, according to reporting party there is no indication that residents are being cleaned by staff because they stopped providing hospice agency stopped bathing resident because facility didn’t give medication for aggressive behavior. LPA observed residents while having breakfast and everyone was well groomed and clean. LPA also toured a random sample of resident’s rooms, and all were observed to be clean and doing their own activities or resting in bed. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 1, 2023 · control 14-AS-20230815111613

Allegation investigated: Staff do not prevent residents from being physically abused by other residents. Staff do not inform resident's authorized representative of incidents as required.

On 08/23/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Resident Care Coordinator Shayla Brewster and Administrator Ollie Vance followed after. LPA explained the purpose of the visit. Regarding the allegation that staff do not prevent residents from being physically abused by other residents, according to the reporting party, Resident 1 (R1) & Resident 2 (R2) were admitted to the facility with abusive behaviors. Interviews were conducted and five out of five family members all have the same observations that they haven’t seen any resident physically abuse another resident without a staff coming right away to either stop the residents or redirect them. While there might be occasions where residents become aggressive, staff member quickly get in the middle deter aggressions. Six out of six staff members have also mentioned that they redirect residents when aggressions start, if they can’t handlethe state’s words, verbatim · CDSS document, Aug 23, 2023 · control 14-AS-20230622161129

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.