Silverado Senior Living - Belmont Hills

Type of visit: Case Management - Incident

On March 24, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit in relation to two incidents that occurred at the facility. LPA met with Administrator, Robert Snee and explained the purpose of the visit. The Licensee reported on 3/8/26 at around 8:00pm, Resident 1 (R1) and Resident 2 (R2) were found together in a room. Both residents were observed half undressed. R1 was observed behind R2 but was not observed touching R2. R1 and R2 were immediately separated and redirected back to their rooms. There were no signs of intimacy or injuries. Licensee implemented 30 minute status checks, reminded staff to redirect and encourage both residents to join activities. All required parties were notified On 3/12/26 at around 6:40pm, the Licensee reported, R1 and R2 were found undressed and involved in an intimate act in a room. Both residents were separated and required parties were notified. Status checks were implemented for every During the visit, LPA reviewed R1 and R2's files, discussed incident with staff, and reviewed the facility's policy regarding resident relationships. According to R1 and R2's file, both residents have Alzheimer's dementia diagnosis and this was the first incident with R1 and R2 being half undressed and being intimate with each other. R1 and R2's service plan was observed to be updated to address these incidents. According to the Assistant Director of Health Services observed R1 and R2 walking around in the courtyard at around 6pm. Administrator and Assistant Director of Health Services indicated that R1 was moved to a different neighborhood and since these incidents, there has not been any new incidents and they have not been observed together. No citations are issued during the visit. Report is reviewed with Assistant Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

On January 5, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to deliver a copy of amended report that was originally delivered on 2/25/25. LPA met with amended administrator, Robert Snee and explained the purpose of the visit. During the visit, LPA delivered an amended copy of LIC9099 and LIC9099D that was issued on February 25, 2025. Report was reviewed with Administrator, Robert Snee and a copy is provided.the state’s words, verbatim · CDSS document, Jan 5, 2026

Type of visit: Case Management - Incident

On December 29, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit to follow up on an incident that occurred on 12/3/25. LPA met with Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reported on 12/3/25, Staff 1 (S1) was assisting Resident 1 (R1) with care when R1 suddenly became agitated and aggressive towards S1. Resident 2 (R2) entered the room and observed R1 being aggressive towards S1. R2 kicked R1's leg and R1 slapped R2's leg. Both residents were immediately separated, assessed for injuries and were placed on behavior mapping. During the visit, LPA observed R1 and R2, discussed the incident with Director of Health Services and Assistant Director of Health Services, and reviewed both residents' files. Based on R1 and R2's file reviewed, both residents have a dementia diagnosis. Based on R1's file reviewed, R1 has a behavior of aggression/agitation and it's towards staff during care. Based on R2's file, he/she had a history of aggressive behavior, however it has improved. During the visit, LPA observed R1 walking around the community and R2 in the dining hall. According to the Director of Health Services and Assistant Director of Health Services, R2 hit R1 because he/she was trying to protect S1 from R1's aggressive behaviors. No residents had injuries noted. No citations are issued during the visit. Report is reviewed with Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Required - 1 Year

On December 29, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Director of Health Services, Amyda Astrero and explained the purpose of the visit. LPA toured the facility inside and outside but not limited to, five resident neighborhoods; maple, cedar, bay, twin pines and oak, one main administrative office, library, and kitchen. No accessible bodies of water or fire safety hazards observed. This is a locked perimeter facility. LPA toured resident neighborhoods and observed a dining room in each neighborhood. Hallways and resident rooms were observed to be clean, odor-free and free from tripping hazards. Nurses/wellness office was observed in Oak and Maple neighborhood. Medications were observed to be locked and inaccessible to residents. Chemicals and sharps were locked and inaccessible from residents. Water temperature throughout the facility measured between 105-117 degrees F. Communal bathrooms were observed to be clean and odor-free. Kitchen was observed two day perishables and seven day non-perishables. A comfortable temperature is maintained and lighting is sufficient for comfort. Fire extinguishers were serviced in 10/2025. Emergency drills are logged and done every three months. LPA reviewed 5 resident files and 5 staff files. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Case Management - Incident

On October 8, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 9/26/25. LPA met with Administrator, Robert Snee and explained the purpose of the visit. On 9/26/25, the Licensee reported Resident 1 (R1) was standing in the dining room when Resident 2 (R2) came up to R1 and leaned his/her head over R1's shoulder. It was observed that R1 punched R2 on the left side of his/her face. Both residents were immediately separated. According to R1, R2 punched him/her first. During the investigation, LPA reviewed R1 and R2's file, observed both residents, and reviewed care plans. Based on both resident's files, R1 and R2 have a diagnosis of dementia. Based on records reviewed, this is the second altercation incident between R1 and R2. According to staff interviewed, verbal training was conducted to ensure both residents are seated separately/ are separated at all times. R2 was seen by his/her physician and there was a medication adjustment. LPA observed both R2 walking around in the courtyard and R1 was observed participating in activities. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Incident

On September 16, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on an incident that occurred on 8/26/25. LPA met with Administrator, Robert Snee and explained the purpose of the visit. On 8/26/25, the Licensee reported at approximately 2:30pm, it was found that Resident 1 (R1) left the community was was observed by a caregiver driving to the facility, that R1 was walking on the sidewalk heading towards Notre Dame School. The caregiver immediately parked, approached R1 and brought R1 back to the community. No injuries were noted. Upon investigation, it was noted that the gate failed to lock. During the visit, LPA reviewed R1's file and toured the facility to observe that locks at the facility. Based on R1's file reviewed, R1 has a diagnosis of dementia. R1 has no history of elopements, however does have wandering behaviors. According to administrator and staff interviewed, the locks failed and the gate did not lock properly. Third party vendor, Lockworks Unlimited arrived the same day to fix the locks and checked all other exit gates to ensure the locks did not fail. During the visit, LPA toured the facility and observed all the exit. All gates were locked. According to the administrator, the gates were also re-keyed. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Case Management - Other

On August 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Administrator, Robert Snee and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility. The letter was given to the Administrator, Robert Snee. This report is reviewed and discussed with the Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

Allegation investigated: Resident sustained pressure injuries in care. Due to staff neglect, resident was dehydrated.

On July 31, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Director of Health Services, Amyda Astrero and explained the purpose of the visit. Regarding the allegation, resident sustained pressure injuries in care, according to the reporting party, Resident 1 (R1) was admitted to the hospital on February 19th with open wounds on both heels. R1 had deep tissue pressure injury on the left heel and a wound on the right heel. During the investigation, LPA interviewed staff, reviewed R1’s file and reviewed medical records. Based on charting notes reviewed, on 2/15/25, the facility reported a right heel wound to R1’s physician and R1’s responsible party. According to R1’s responsible party, it was noted that R1 has a history of pressure ulcer. According to interviewed staff, R1’s physician sent a referral to home health wound nurse, however on 2/19/25, R1 was sent to the ER and was told by R1’s responsible party that home health called to notify R1’s responsible party that they are coming to the facility, however cancelled because R1 was still admitted at the hospital. (continue to 9099C) Unsubstantiated Based on photos, facility wound care notes, home health wound care notes, and interviews conducted, R1 returned to the community on 3/7/25 with wounds on both heels. Home health wound nurse came into the facility for wound care 3x a week. On 4/11/25, R1 was admitted to hospice. Regarding the allegation, due to staff neglect, resident was dehydrated, according to the reporting party, R1 was admitted to the hospital on 2/19/25 for dehydration. During the investigation, LPA interviewed staff. According to staff interviewed, the facility was notified that R1 had a history of dehydration. Because the facility is not a skilled nursing facility, they don't log water intake, however since facility staff were aware of the history of dehydration, the facility staff ensured to monitor R1's water intake. Facility staff indicated that a water bottle was also purchased for R1 so that staff are aware how much water R1 is drinking a day. Based on interviews conducted, documents reviewed and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 14-AS-20250320161225

Type of visit: Case Management - Incident

On July 31, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on July 8, 2025. LPA met with Director of Health Services (DHS), Amyda Astrero and explained the purpose of the visit. The Licensee reported, on 7/8/25, a med-tech reported to the DHS that Staff 1 (S1) reported on 7/6/25, Resident 1 (R1) refused to go out of his/her room because he/she was afraid of Staff 2 (S2). The med-tech spoke to R1 and R1 indicated that S2 is rough to R1 and pushed R1 against the wall. DHS conducted an investigation and asked R1 is he/she knew the staff and R1 stated S2's name and stated S2 threw him/her against the wall and left him/her in a bad position. No injuries were notes. S2 was suspended pending investigation. During the investigation, LPA reviewed R1's file, reviewed facility's investigation and attempted to interview S2 and R1. R1 was not interviewable during the visit as he/she was eating lunch. S2 was not working during the time of the visit. Based on R1's file reviewed, R1 has a diagnosis of dementia, however does not have any aggressive or violent behaviors. According to the DHS, this is the first time R1 accused a staff of being aggressive towards him/her. Based on the facility's investigation, the findings went unsubstantiated as no staff member from the PM shift on 7/6/25 witnessed the incident. DHS provided training documents for S2 and will complete an in-service training with all staff on 7/31/25. According to the DHS, S2 is back to work, however is in a different neighborhood from R1. No citations are issued during the visit. Report is reviewed with Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Other

On June 4, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit. LPA met with Director of Health Services, Amyda Astrero and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude an Staff 1 (S1) and Staff 2 (S2) from the facility. The letter was given to the Director of Health Services. This report is reviewed and discussed with the Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Type of visit: Case Management - Incident

On May 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management in relation to an incident that occurred on 4/27/25. LPA met with Administrator, Robert Snee and explained the purpose of the visit. On 4/27/25, the Licensee reported, the facility's engagement assistant (S1) observed Resident 1's (R1's) 1:1 caregiver sitting outside the door holding the door knob preventing R1 from leaving the room. All required parties were notified. New medications were ordered and 1:1 caregiver was terminated. During the visit today, LPA interviewed staff and reviewed R1's file. Based on file reviewed, R1 has a diagnosis of advanced dementia and a previous history of aggressive behavior, however was on medication to stabilize his/her aggressive behaviors. R1's behavior stabilized so the physician stopped the medication, however R1 started having aggressive behaviors. According to staff interviewed, the 1:1 caregiver was through a third party vendor/agency the facility uses, however the family contracted with the vendor/agency directly. The Director of Health Services indicated, when S1 witnessed 1:1 caregiver sitting outside holding R1's door knob preventing R1 from leaving his/her room, S1 immediately let R1 out of the room and walked him/her around outside. 1:1 caregiver is no longer allowed to come back to the facility and another 1:1 caregiver was hired to assist R1. R1 has a weekly psychiatrist appointments and medication management has been implemented. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 27, 2025

Allegation investigated: Staff did not seek timely medical attention for a resident

**This is an amended copy of the report that was issued on February 25, 2025. An amended copy of LIC9099 and LIC9099D will be provided during visit on January 5, 2026.** On February 25, 2025, Licensing Program Analyst (LPA) Komal Charitra conuducted an unannounced complaint visit to deliver the finding for the above allegations. LPA met with Administrator, Robert Snee and explained the purpose of the visit. Regarding the allegation, staff did not seek timely medical attention for resident, according to the reporting party, on 12/23/24, Resident 1 (R1) had a witnessed fall at 11am and the facility did not seek timely medical attention until 4:54pm when R1's responsible party told S1 to call 911 after calling for an update and being notified by Staff 1 (S1) that R1 is in severe pain and can't move his/her leg. During the investigation, LPA interviewed administrator, staff, and reviewed documentation. Based interviews conducted, 3/3 staff members indicated R1 had a witnessed fall at 11am and complained of pain. Staff immediately responded, assisted R1 from the floor and assessed R1. S1 and Staff 2 (S2) indicated that they reached out the the doctor for advice, however the doctor was not responding. S1 and S2 checked on R1 throughout the day and R1 still complained of pain. (Continue to 9099C) Substantiated S2 who was on the AM shift admitted that he/she should have called 911 immediately after resident had a fall and complained of pain, however indicated because resident was not in severe pain, S2 did not call 911. S1 who was on shift during the PM shift, indicated he/she was not sure why the facility did not send R1 to the hospital after the fall in the morning. The facility did not send R1 out to the hospital till about 5:30pm when R1 started moaning, complaining of pain, and couldn't move his/her legs. Based on medical records reviewed, due to the fall, R1 sustained a left hip fracture. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS STAFF DID NOT SEEK MEDICAL ATTENTION FOR A RESIDENT. THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. According to the administrator and the Director of Health Services, the facility's protocol is to have the shift nurse call responsible parties regarding incidents that occur before they leave their shift. The facility did notify R1's responsible party based on interview conducted with S2, administrator and Director of Health Services. Based on care notes reviewed, it was observed that S2 did contact R1's responsible party. 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 is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 14-AS-20241227093734

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Feb 26, 2025

87465 Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. This requirement is not met as evidenced by: Licensee failed to seek timely medical attention after R1 had a fall and complained of pain. Based on interviews and records reviewed, R1 had a fall at 11am and R1 was not sent out to the hospital till about 5:30pm. Based on interview conducted with S2, S2 admitted that 911 should have been called immediately after R1 had a fall and complained of pain, however indicated because resident was not in severe pain, S2 did not call 911. Nevertheless, R1 complained to 3 staff members of pain and observed by staff of having pain and the facility did not seek medical attention for R1 which poses an immediate health risks to residents in care and resulted into a left hip fracture.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Licensee/administrator shall submit a plan in writing addressing how to seek timely medical attention. Civil penalty in the amount of $500.00 is being assessed today as the facility failed to seek timely medical treatment for Resident 1 (R1) after an incident that occurred on 12/23/24 which resulted in a fractured left hip.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jan 6, 2026

87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2)... This regulation is not met as evidenced by: Licensee failed to seek timely medical attention after R1 fell and immediately complained of pain. Staff interviewed admitted that R1 needed to go to the hospital but chose to wait stating R1 was not in enough pain. R1 had a severe injury and could not move their leg. Staff left R1 to endure pain for hours from approximately 11am to 5:30pm without seeking emergency medical services which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Licensee completed an in-service training on 12/30/24 with nurses in relation to responding to change of condition and when to call 911. Deficiency cleared.

Type of visit: Required - 1 Year

On December 3, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Robert Snee and explained the purpose of the visit. LPA toured facility and grounds including but not limited to, five resident neighborhoods; maple, cedar, bay, twin pines and oak, one main administrative office, library, and kitchen. No accessible bodies of water or fire safety hazards observed. LPA toured resident neighborhoods and observed a dining room in each neighborhood. Dining room and hallways were clean and free from any tripping hazards. Resident rooms were observed clean, odor-free, with all required furniture. Nurses station was observed in the Oak and Maple neighborhood. Medications were observed to be locked and inaccessible to residents. First aid kits were observed to be present and complete. Toxins and chemicals were locked and stored away in a storage room. Water temperature throughout the facility measured between 105-115 degrees F. Communal bathrooms were observed to be clean and odor-free. Kitchen was observed two day perishables and seven day non-perishables. Lighting and temperature throughout the facility was sufficient for comfort. Fire extinguishers were mounted and serviced in 10/2024. Emergency drills are logged and done every three months. LPA reviewed 5 resident files and 5 staff files. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Case Management - Incident

On March 15, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCL. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reported on March 11, 2024 at approximately 12:05pm, Resident 1 (R1) was found by Resident Care Coordinator outside near the community parking lot in a wooded area. R1 was escorted back into the community and was assessed by the nurse. Based on facility's internal investigation, perimeter gates were all closed, locked and in working order; no evidence of equipment or rocks were visible to indicate gate was propped open. There were no signs of equipment or furniture to indicate that R1 could've climbed the gates. Facility initiated behavior mapping for R1 and conducted rounds to ensure all gates were locked and secure. In addition, on the same day, March 11, 2024 at approximately 6:25pm, while conducted rounds, staff reported that R1 was not in the dining room. Staff immediately started searching for R1. Med-tech found R1 walking around on the other side of the gates near the Bay neighborhood, close to a picnic area. R1 was redirected back into the community, assessment was done by nurse, and a one on one caregiver was assigned to R1. Community perimeters were checked again, all gates were observed locked. Locksworth Unlimited inspected the gates. During the visit, LPA reviewed R1's file, observed R1 eating lunch. R1 is currently residing in Twin Pines neighborhood where there is more staff present. Based on R1's file, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. Behavior mapping log was observed. Facility conducted 30-minute status checks after the first incident occurred at 12:05pm. According to Administrator and Director of Health Services, R1 does not have a history of AWOL, however R1's responsible party takes R1 out of the community for several days at a time which; recent outing was hiking from 3/5/2024 - 3/10/2024. Updated service plan was observed. No citations issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Mar 15, 2024

Type of visit: Case Management - Other

On February 16, 2024, Licensing Program Analyst (LPA) Komal Charitra met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero for a Case Management visit to follow up on a substantiated complaint allegation of neglect and lack of supervision resulting in serious bodily injuries. On October 10, 2019, the Department concluded a complaint investigation which alleged that the facility did not provide proper care and supervision which resulted in a resident (R1) sustaining multiple falls including a serious bodily injury. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464(f) Basic Services. The investigation revealed the facility failed to do an accurate fall risk assessment after R1 experienced multiple fall incidents at the facility on June 17, 2018, July 15, 2018, October 11, 2018, October 17, 2018, and December 19, 2018. As a result, the facility failed to identify and implement measures and or plan of care changes to minimize further fall incidents for R1. Based on documentation reviewed, according to the facility’s assessment, it was not identified that R1 was a high risk for falls. On March 1, 2019, R1 had another unwitnessed fall and was hospitalized. Based on the investigation, it was revealed that there are three small buildings on this property. There were no caregivers present in R1’s building before or at the time R1 fell. Two caregivers were in another building and a licensed vocational nurse (LVN) was in a med room, but the LVN was not answering their phone. As a result of the improper risk assessment and facility’s failure to identify and implement a proper plan of care to address R1’s fall risk; R1 sustained a right intertrochanteric femur fracture and needed to undergo an operation called femur intramedullary rodding. (Continue to 809C) In addition, based on the documents and information collected, the investigation revealed that the facility was aware of R1’s multiple falls, but continued to provide care based on inaccurate fall risk assessments, outdated plan of care, and did not notify the Primary Care Physician (PCP) of the changes until R1’s fall on March 1, 2019. There was no facility report or documentation available for review to indicate facility staff or the administrator had notified the PCP about R1’s fall history or a plan of care necessary to minimize R1’s risk for falls. At the time of the complaint visit on October 10, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to provide the proper care and supervision to R1, knowing that R1 was a fall risk, resulting in R1 falling and sustaining a right intertrochanteric femur fracture, which is serious bodily injury. Today, February 16, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 10, 2019, the amount of the civil penalty issued today will be $9500. A copy of the LIC 421D was given to Administrator, Robert Snee and originals were signed. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator, Robert Snee signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Required - 1 Year

On January 31, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. LPA toured facility and grounds including but not limited to, five resident neighborhoods; maple, cedar, bay, twin pines and oak, one main administrative office, library, and kitchen. No accessible bodies of water or fire safety hazards observed. LPA toured resident neighborhoods and observed a dining room in each neighborhood. Dining room and hallways were clean and clear for hazards. Resident rooms observed had all required furniture and were observed to be clean. Nurses station was observed in the Oak and Maple neighborhood. Medications were observed to be locked. First aid kits were observed to be present and complete. Three laundry rooms and one main laundry room was observed to be locked. Toxins and chemicals were locked and stored away in a storage room. Water temperature throughout the facility measured between 112-118.9 degrees F. Six communal bathrooms were observed to be clean and odor-free. Kitchen was observed to be clean. Kitchen was observed two day perishables and seven day non-perishables. Lighting throughout the facility was sufficient for comfort. A comfortable temperature of 71 degrees F is maintained. Fire extinguishers were mounted and serviced in 10/2023. Emergency drills are logged and done every three months. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are observed during the visit. Report is reviewed with the Administrator and Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Case Management - Incident

On December 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on December 10, 2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. On December 10, 2023, the Licensee reported that a staff member observed Resident 1 (R1) and Resident 2 (R2) in the room together. It was reported that R1 was touching R2's chest area. R1 has a 24/7 one-on-one private caregiver assigned to him/her, however during the time of the incident, the private caregiver went to use the restroom and left R1 unattended without telling a staff member. During the visit, LPA reviewed R1's file, interviewed administrator and director of health services. According to Administrator and Director of Health Services, agency caregivers are required to contact the nurse's station and notify a staff member prior to going on break/lunch so a staff member can be assigned to be R1's companion while the agency caregiver is on break. Based on R1's file, this is the the third incident involving R1 touching another resident inappropriately; previous incidents occurred 11/7/2023 and 11/8/2023. A 24/7 private agency caregiver was assigned on 11/8/2023. Facility was unable to provide LPA an orientation checklist or training provided to the private one-on-one agency caregiver regarding breaks/lunches. Based on documents reviewed and interviews conducted, facility failed to provide orientation/training to the private on-on-one agency staff member assigned to R1 which resulted to R1 being left unattended. Nevertheless, due to R1 being left unattended, R1 was observed in the room with R2 touching his/her breasts. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with the administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Dec 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 20, 2023

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by: Based on interviews conducted and documents reviewed, the facility failed to provide orientation/training to the private on-on-one agency staff member assigned to R1 which resulted to R1 being left unattended. Nevertheless, due to R1 being left unattended, R1 was observed in the room with R2 touching his/her breasts.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Licensee/Administrator to create a checklist and/or documented training for all one-on-one agency caregivers. Checklist/training to include; protocols when taking breaks and lunches.

Type of visit: Case Management - Incident

On December 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on two incidents that was reported to CCLD. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reported on 11/7/2023, Resident 1 (R1) was observed holding Resident's 2 (R2's) hand. It was observed by a caregiver that R1 reached over and touched R2's breasts. Caregiver immediately separated R1 and R2. R1 was placed on 30-minute checks, facility called responsible party to request a one-on-one caregiver, and facility called R1's physician to review R1's medications. The Licensee reported on 11/8/2023 around 4:30pm, R1 observed walking by R2 and gilded his/her hang over Resident 3's (R3's) breast area. Caregiver separated both residents at the time. One one one caregiver for R1 was provided at 6:30pm on 11/8/23, physician adjusted R1's medication, behavior mapping is on-going. During the visit, LPA reviewed R1's file, observed R1 and discussed the incidents with Administrator and Director of Health Services. Based on R1's record review, R1 has a diagnosis of Alzheimer's Dementia and does not have any inappropriate or aggressive behaviors. Based on observations, R1 was in the dining room with R1's one-on-one caregiver. According to the administrator and director of health services, R1 has not had any inappropriate incidents since the one-on-one caregiver was assigned and facility will continue to monitor R1. Director of Health Services will set up a meeting with R1's physician and responsible party and conduct a re-assessment for R1. No deficiencies are cited today. Report is reviewed with Administrator and Director of Health Services and a copy is provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

Type of visit: Case Management - Other

On September 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit. LPA met with Administrator, Robert Snee, Director of Health of Services, Amyda Astrero and Assistant Director of Health Services, Hazel Yabut and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude an employee of the facility. The letter was given to the Administrator. This report is reviewed and discussed with the Licensee and a copy is provided.the state’s words, verbatim · CDSS document, Sep 29, 2023