Silverado Senior Living-Beach Cities

Type of visit: Office

On June 30, 2026, an office meeting was held to discuss possible additional civil penalties for Complaint 11-AS-20250709112537 regarding the allegation “Due to staff neglect, resident sustained injuries”. Attendees included Licensing Program Manager (LPM) Ulysses Coronel, Licensing Program Analyst (LPA) Regina Cloyd, Licensee Representative/Regional Vice President of Operations Tana McMillon and Administrator Lourdes Menchaca. The following topics were discussed: • Possible additional civil penalties • Appeal rights for the additional civil penalties • The Department’s offer of the Technical Support Program (TSP) There were no deficiencies cited during today’s meeting. An exit interview was conducted, and a copy of this report and the Complaint Investigation Report were provided to Administrator Lourdes Menchaca.the state’s words, verbatim · CDSS document, Jun 30, 2026

Allegation investigated: Due to staff neglect, resident sustained injuries.

This report supersedes the report delivered on 04/07/2026 and the findings do not change. On 04/29/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Administrator Lourdes Menchaca and the purpose of the visit was explained. Investigation consisted of the following: On 07/16/2025, LPA obtained Resident Roster (as of 07/01/2025), staff schedule, June 2025 and July 2025 Medication Administration Record (MAR), Physicians Report, Plan of Care, Vitals, and Progress Notes for Residents #1-10. LPA interviewed nine staff members (S1 – S9) and four witness interviews (W1 – W4) and toured the first and fourth floor. On 10/13/25, LPA received a Personnel Record (10/13/25). On 10/17/25, LPA received R1’s Providence Little Company of Mary Torrance Medical Record. On 11/03/25, LPA left a voicemail for Staff #10. On 11/12/26 and 11/16/26, LPA left a voicemail for Staff #11. On 11/29/25, LPA received R1’s death certificate. On 01/12/26, LPA interviewed Staff #10 (S10) and Staff #11 (S11). Continue to LIC9099-C. Substantiated On 01/27/26, LPA interviewed Staff #12 (S12). On 03/23/26, LPA received the second-floor facility sketch. On 04/29/26, LPA interviewed attempted to interview ten residents in memory care but they were unable to coherently answer the questions. Investigation revealed the following: Regarding the allegation, “Due to staff neglect, resident sustained injuries,” it is alleged Resident #1’s (R1) fall resulted in lacerations all over R1’s body. Record review of R1’s Hospital Physical Therapy OPIB Plan of Care revealed R1 fell (04/08/25) prior to admission and sustained a fracture on part of the hip joint. R1 was non-weightbearing for six weeks. Record review of R1’s Physician’s Report (04/21/25) revealed R1 is non weight bearing on right lower extremity and needs assistance with toileting needs. Review of Service Plan (06/01/25) revealed R1 was dependent on staff members for all mobility/ambulation needs, required hands on assistance by staff members, able to hold weight for few steps with one-person assist but then becomes weak. R1 was a fall risk and needed to be monitored and assisted as needed for safety. R1 requires routine toileting program. Review of Incident Report (Occurred 07/04/25) indicated that R1 had an unwitnessed fall in R1’s room that resulted in skin tears on both hands, an abrasion on the left knee, and noted hypotension. R1 was transferred to the hospital for further evaluation. Review of Hospital Record (ED Provider Note, 07/04/25) revealed R1’s open right finger wound (laceration with tendon exposed) was repaired using local anesthesia and suturing. R1 was given intravenous antibiotics to prevent infection of the open wound. Interview with Staff #1 (S1) indicated R1 had dinner, watched television in the common area, and then went to R1’s bathroom. S1 indicated R1 was toileting and had an unwitnessed fall. R1 was found on the floor with the walker in front of R1. S1 indicated staff does assist R1 but if R1 goes there [bathroom], R1 will toilet independently. Two out of three caregivers (S10 – S12) working on the second floor at that time indicated they did not assist R1 to the bathroom. The third caregiver could not recall R1's incident nor working that day. Regarding the allegation, “Due to staff neglect, resident sustained injuries” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil penalties are being assessed, see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. An exit interview was conducted, plans of correction were developed and appeal rights provided on 04/07/26 and a copy this report was left with Administrator Lourdes Menchaca.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 11-AS-20250709112537

Allegation investigated: Due to staff neglect, resident sustained injuries.

On 04/07/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Administrator Lourdes Menchaca and the purpose of the visit was explained. Investigation consisted of the following: On 07/16/2025, LPA obtained Resident Roster (as of 07/01/2025), staff schedule, June 2025 and July 2025 Medication Administration Record (MAR), Physicians Report, Plan of Care, Vitals, and Progress Notes for Residents #1-10. LPA interviewed nine staff members (S1 – S9) and four witness interviews (W1 – W4) and toured the first and fourth floor. On 10/13/25, LPA received a Personnel Record (10/13/25). On 10/17/25, LPA received R1’s Providence Little Company of Mary Torrance Medical Record. On 11/03/25, LPA left a voicemail for Staff #10. On 11/12/25 and 11/16/25, LPA left a voicemail for Staff #11. On 11/29/25, LPA received R1’s death certificate. On 01/12/26, LPA interviewed Staff #10 (S10) and Staff #11 (S11). On 01/27/26, LPA interviewed Staff #12 (S12). On 03/23/26, LPA received the second-floor facility sketch. Continue to LIC9099-C. Substantiated Investigation revealed the following: Regarding the allegation, “Due to staff neglect, resident sustained injuries,” it is alleged Resident #1’s (R1) fall resulted in lacerations all over R1’s body. Record review of R1’s Hospital Physical Therapy OPIB Plan of Care revealed R1 fell (04/08/25) prior to admission and sustained a fracture on part of the hip joint. R1 was non-weightbearing for six weeks. Record review of R1’s Physician’s Report (04/21/25) revealed R1 is non weight bearing on right lower extremity and needs assistance with toileting needs. Review of Service Plan (06/01/25) revealed R1 was dependent on staff members for all mobility/ambulation needs, required hands on assistance by staff members, able to hold weight for few steps with one-person assist but then becomes weak. R1 was a fall risk and needed to be monitored and assisted as needed for safety. R1 requires routine toileting program. Review of Incident Report (Occurred 07/04/25) indicated that R1 had an unwitnessed fall in R1’s room that resulted in skin tears on both hands, an abrasion on the left knee, and noted hypotension. R1 was transferred to the hospital for further evaluation. Review of Hospital Record (ED Provider Note, 07/04/25) revealed R1’s open right finger wound (laceration with tendon exposed) was repaired using local anesthesia and suturing. R1 was given intravenous antibiotics to prevent infection of the open wound. Interview with Staff #1 (S1) indicated R1 had dinner, watched television in the common area, and then went to R1’s bathroom. S1 indicated R1 was toileting and had an unwitnessed fall. R1 was found on the floor with the walker in front of R1. S1 indicated staff does assist R1 but if R1 goes there [bathroom], R1 will toilet independently. Two out of three caregivers (S10 – S12) working on the second floor at that time indicated they did not assist R1 to the bathroom. The third caregiver could not recall R1's incident nor working that day. Regarding the allegation, “Due to staff neglect, resident sustained injuries” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil penalties are being assessed, see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. An exit interview was conducted and plans of correction were developed and a copy this report with appeal rights were left with the Administrator Lourdes Menchaca.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20250709112537

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 8, 2026

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by: Based on record review and interviews, on 07/04/2025, R1 was not provided with toileting assistance by staff, resulting in R1's fall and serious injuries, which posed an immediate safety risk to client in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: The Administrator will create a plan to ensure residents who require toileting assistance are provided with the service by staff. The plan can be emailed to regina.cloyd@dss.ca.gov by the POC due date.

Type of visit: Required - 1 Year

On 03/20/2026, Licensing Program Analysts (LPAs) Regina Cloyd and Socorro Leandro conducted an unannounced annual inspection and met with Administrator Lourdes Menchaca. The purpose of the visit was explained. The facility is licensed to serve one hundred twenty (120) non-ambulatory residents age range 60 and over and has a hospice waiver for thirty (30). Annual fees are current. During today's visit, LPAs reviewed resident and facility records, conducted facility tour, and reviewed one resident's medication. Deficiencies are being cited according to California Code of Regulations, see LIC809-D. During medication review, Resident #1's (R1) Medication Administration Record (02/01/26 - 03/20/26) for six medications did not match the quantity of the medication on hand based on the package open date. Interview with the Administrator (S1) revealed S1's Residential Care for the Elderly Certification has been expired as of April 2025. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report with appeal rights was provided to the Administrator Lourdes Menchaca.the state’s words, verbatim · CDSS document, Mar 20, 2026

Allegation investigated: Staff did not respond to a resident's call button in a timely manner. Licensee does not ensure that facility call system is operable.

On 02/20/2026, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Lourdes Menchaca, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA inspected the facility, tested the call buttons in nine (9) resident rooms, interviewed residents’ Responsible Party W2-W6, and received and reviewed In-Service Training Logs. During the initial visit conducted on 11/25/2025, LPA toured the facility, interviewed Staff S1-S10, interviewed Residents R2-R11, interviewed resident's Responsible Party W1, and received and reviewed the Staff Roster, Resident Roster, Staff Schedule, Maintenance Program Policy & Procedure for Call System Monitoring, Call System Testing Logs, Admission Agreement, Physician’s Report, Service Plan Details, and Resident Identification and Emergency Information Worksheets. The investigation revealed the following: Unsubstantiated Allegation: Staff do not respond to residents’ call buttons in a timely manner. The allegation alleges that when residents press their call button staff do not come in a timely manner or do not respond. During the facility inspection, LPA pressed nine (9) call buttons in resident rooms to document the staff’s response time. LPA pressed the call buttons in room’s 102,112, 203, 211, 303, 311, 403, 405, and 411 and the staff’s response time was under a minute for each room. When LPA pressed the call button, they could hear the staff’s walkie talkie announce “room (number) activated” and when it was cleared, by pressing the call button again, it announced “room (number) restored.” During record review LPA received and reviewed the Staff Schedule and observed during the NOC shift there are four (4) caregivers and two (2) LVNs scheduled. During the AM shift there are four (4) LVNs and ten (10) caregivers scheduled. Durning the PM shift there are four (4) LVNs and ten (10) caregivers scheduled. Additionally, LPA received and reviewed staff In-Service Log for 11/23/2025 regarding the Walkies and Routine Visual Checks Every 2 Hours. During interviews with Staff S1-S9, were asked how long it takes to respond to residents’ calls for assistance, nine (9) out of nine (9) stated they respond right away unless they are assisting another resident it could take five (5) minutes. During interviews with Residents R2-R11, were asked if staff respond to call buttons in a timely manner, ten (10) out of ten (10) stated staff come right away. During interviews with resident’s Responsible Party W1-W6, were asked if residents call for assistance is answered in a timely manner, six (6) out of six (6) stated yes staff respond right away. Allegation: Licensee does not ensure that facility call system is operable. The allegation alleges the walkie-talkies were not working properly and there were problems with the audio, and the volume does not work all the time. During the facility inspection, LPA tested nine (9) call buttons in resident rooms to document the staff’s response time. LPA pressed the call buttons in room’s 102,112, 203, 211, 303, 311, 403, 405, and 411 and observed they are working properly. During record review LPA received and reviewed the facility’s Plan of Operation that states on page 24 “A non-computerized nurse call system will be tested a minimum of every two weeks. The testing will include all call lights in resident rooms, bathrooms, showers, tub rooms and the call light panel.” Additionally, LPA received and reviewed the Call System Monitoring logs from 01/01/2025 to 11/16/2025. The logs indicate that the system was tested on the following days in November 2025, 11/02/2025, 11/09/2025, and 11/16/2025. The only comment was listed on 11/09/2025 that states room 213’s battery was replaced. During interviews with Staff S1-S10, they were asked if the call buttons are operable, ten (10) out of ten (10) stated the call buttons are operable. Additionally, Staff S1 and S10 stated the call buttons are tested every one (1) to two (2) weeks. During interviews with Residents R2-R11, were asked to their knowledge do the call buttons work, eight (8) out of ten (10) stated yes, their call buttons work in their room. Two (2) out of ten (10) stated they do not use the call buttons and are not sure if they work properly. During interviews with resident’s Responsible Party’s W1-W6, were asked if their residents call button is operable, five (5) out of six (6) stated yes, their resident’s call button was operable. One (1) out of five (5) stated they are unsure if it works properly due to their resident not using it. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Lourdes Menchaca, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 11-AS-20251121105507

Type of visit: Required - 1 Year

On 5/8/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Lourdes Yvette Menchaca/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (120) elderly adults ages 60 and above, of which (120) can be non-ambulatory. The facility has an approved hospice waiver for (30). Currently the facility has (94) residents. The facility is a four-story structure located in a commercial building in a residential neighborhood. The facility consists of: (110) bedrooms, (71) bathrooms, 1st floor, 2nd floor, 3rd floor, and 4th floor, which are mirror images of themselves. All the floors contain a lounge/movie room, a kitchenette, clean linen rooms, mechanical rooms, and an activities/dining room. Activities storage room, wellness room, nursing supplies, laundry chute room. 1st floor has a fireplace in the lounge room, a shaded side yard with a gazebo, plants, and a play area, 2nd floor has an incontinence room/staff lounge, and 4th floor has a PT/gym room. The basement has a kitchen, a laundry room, and PPE storage. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Smoke and carbon monoxide detectors were in operable condition. The water temperature measure 129.F°. and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in dementia unit. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/22/25. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Facility staff not associated at the facility. Civil Penalty rendered for $500.00. -Water temperature in resident’s bathrooms at 129F and 126F. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Lourdes Yvette Menchaca / Administrator.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Required - 1 Year

On 3/13/2024, Licensing Program Analysts (LPAs) Alfonso Iniguez and Darneisha Cross conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Lourdes Menchaca / Administrator. LPAs explained the purpose of today’s visit. The facility is licensed to serve (120) residents ages 60 and above. Of which (120) may be non-ambulatory. Approved hospice waiver for (30). Currently the facility has 87 residents. The facility is a (4) four story structure located in a commercial building in a residential neighborhood. The facility consists of; (110) bedrooms, (71) bathrooms, 1st floor, 2nd floor, 3rd floor, and 4th floor are mirror image of themselves. all the floors contain lounge / movie room, kitchenette, clean linen rooms, mechanical rooms, activities/dining room. activities storage room, wellness room, nursing supplies, laundry chute room. 1st floor has a fireplace in lounge room, shaded side yard with gazebo, plants, and play area, 2nd floor has an incontinence room/staff lounge, and 4th floor has PT/gym room. The basement has (kitchen, laundry room, and PPE storage.) LPAs toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected: Rooms: 105, 113, 202, 208, 301, 308, 404, 411. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA reviewed last date fire inspection company came to check smoke detectors. The water temperature properly measured between 105F. and 120 F. Evaluation Report Continues LIC 809-C LPAs Iniguez and Cross observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed, cleaning agents and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (7) residents' service files, (7) staff personnel files were checked. (7) Medication Administration Records (MAR) were reviewed no discrepancies were found. First AID kit was checked. Last fire disaster drill was on:2/27/2024. LPA observed the facility's infection control practices. Liability insurance will be emailed to LPA. Facility Annual Fess not Current, LPA gave PIN:221826 to Administrator during the visit. Administrator stated that company will send an overnight check to CDSS. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Lourdes Menchaca /Administrator.the state’s words, verbatim · CDSS document, Mar 13, 2024