Silverado Senior Living - Newport Mesa

Allegation investigated: Medication not being administered as prescribed Staff failed to address a change in resident's health condition

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 05/02/2023. **Continued on 9099-C page Unsubstantiated Medication not being administered as prescribed Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff failed to address a change in resident's health condition Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20230502140537

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Executive Director (ED) Heather Younan and explained the purpose of the inspection. During the inspection, LPA and ED toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized. LPA observed utility services operational. LPA requested and reviewed copies of resident roster, staff roster, and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, four (4) dining areas, kitchen, and outside covered patio area. Residents reside on the first floor only. Administrator (AD) Heather Younan was present to conduct facility tour. AD provided updated liability insurance that expires on 7/1/2026. Around 9:30am LPA toured inside and outside grounds of the physical plant with AD. There were no bodies of water or obstructions on the premises. There is shaded outdoor seating. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Six resident rooms were inspected. Bathrooms were found clean and operational. Toilets and water faucets worked properly, grab bars were secure and showers were free of mold/mildew. The water temperature measured at 106.5 to 116 degrees F. LPA observed the emergency food and water supply. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The kitchen is inaccessible to residents. Emergency food & water was observed to be adequate. Facility provided documentation dated September 11, 2025 by Lindley Systems stated all smoke detectors, and carbon monoxide detectors were operable. Facility's last conducted Fire/Safety Drill on November 14, 2025. Drills are done quarterly. LPA observed residents participating in activities. First Aid Kit contained all the necessary elements. LPA reviewed six resident files and six staff files. Medications were audited for five residents. Medications are stored in the medication room inside locked carts. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 17, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility did not implement interventions to prevent residents from eloping.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Facility did not implement interventions to prevent residents from eloping. During the investigation it was discovered that the complaint allegation was made against the wrong facility. After touring the facility with Staff 1 (S1) documents were requested. Shortly after documents were requested, it was discovered the complaint was indeed filed against the wrong facility. LPA confirmed this by a review of FAS before closing the investigation and informing staff what happened. Based on the information gathered during the pre-investigation and document review, the following allegation above, is deemed Unfounded, meaning the allegation is false and could not have happened. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 17, 2025 · control 22-AS-20251010143913

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias conducted a Case Management visit to the facility to obtain information pertaining to a self reported incident for an elopement involving resident 1 (R1). R1 eloped the facility and returned to their original residence. The facility submitted the incident report on 09/15/2025. The report indicated that the incident occurred on 09/14/2025. LPA observed various residents throughout the facility. Residents in care appeared to be safe; no imminent health/safety concerns were observed. LPA inspected the inside of facility. Facility appeared to be clean and organized. LPA inspected outside perimeter of facility, to ensure no health/safety hazards were present. The needs of the residents in care appeared to be met during LPA's inspection. LPA obtained copies of pertinent documents and interviewed staff. R1 has not returned since the incident occured and is currently at the hospital. LIC602 physician's report indicates R1 may not leave the facility independently. R1's service plan indicates R1 exhibits wandering behaviors. Interviews with staff revealed elopement behaviors were known and one prior elopement was attempted earlier in the day the same day the R1 eloped. R1 was left alone for approximately 6 minutes during which R1 eloped at approximately 12:48pm. Facility notified law enforcement, responsible party, and DHS, Based on today’s inspection a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at facility along with appeal rights.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Sep 17, 2025

Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by: Facility did not ensure supervision of resident with continued safety when wandering from the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: AD stated one on one supervision will be in place when R1 returns. In addition an air tag will be place in R1's show to track location. AD added only associates will supervise R1 and no longer utilize students to supervise.

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Andrea Mendevil and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, 4 dining areas, kitchen, and outside covered patio area. Resident reside on the first floor only. Administrator (AD) Heather Younan was present to conduct facility tour. AD provided updated liability insurance that expires on 7/1/2025. Around 9:20am LPAs toured inside and outside grounds of the physical plant with AD Younan. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Five resident’s rooms were inspected. Bathrooms were found clean and operational. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. The water temperature measured at 106.3-121.4 degrees F. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The kitchen is inaccessible to residents. Emergency food & water was observed to be adequate. Facility provided documentation dated June 4, 2024 by Fire Safety Service confirming all smoke detectors, and carbon monoxide were operable. Facility's last conducted Fire/Safety Drill on January 16, 2025. Drills are done quarterly. LPA's observed Department posters were posted. First Aid Kit contained all the necessary elements. LPAs reviewed five resident files and five staff files. Medications were audited for 5 residents. Medications are stored in the medication room inside locked carts. CONTINUED ON LIC808-C DATED 2/21/2025 Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Required - 1 Year

On May 10, 2024, at 8:30am, Licensing Program Analysts (LPAs) Jenifer Tirre and Edward Kim conducted an unannounced required 1-year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Tirre and Kim met with Administrator (AD) Heather Younan and explained the purpose of the visit. The facility census is fifty-three (53) residents. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, 4 dining areas, kitchen, and outside covered patio area. Around 9:20am LPAs Tirre and Kim toured inside and outside grounds of the physical plant with AD Younan. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Three resident’s rooms were inspected. Bathrooms were found within Title 22 regulations and were clean and operational. The water temperature measured at 111.2-118.5 degrees F. A comfortable temperature of 68-74 degrees F was maintained in the facility. LPA's observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food & water was observed to be adequate. Three fire extinguishers were checked and all were charged and mounted. Facility provided documentation by Fire Safety Service confirming all smoke detectors, and carbon monoxide were operable during facility's last conducted Fire/Safety Drill on March 6, 2024. Drills are done quarterly. A working telephone (949-631-2212) remains available. Proof of Liability Insurance is valid (7/1/2023-7/1/2024). First Aid Kit contained all the necessary elements. Evaluation Report Continues on LIC 809-C During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA's observed Department posters were posted. The Administrative Certificate expires June 9, 2025 for Heather Younan. During the visit, LPAs conducted a full audit of all staff files, resident files, and medications. LPAs conducted three (3) resident interviews and six (6) staff interviews. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Administrator Younan.the state’s words, verbatim · CDSS document, May 10, 2024

Allegation investigated: Staff are not providing adequate care to dementia residents.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced subsequent visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Heather Younan. During the course of the investigation LPA toured facility, conducted interviews, made visual observations and requested pertinent documentation such as Personnel Report, Employee caregiver rounds, resident roster and employee listings. During investigation LPA reviewed facility records such as Personnel report, Employee listings and Care Giver Daily rounds shift schedule dated March 11, 2024. Records reviewed revealed that Facility has 25 Caregivers, eight Licensed Vocational Nurses and two Med Tech’s who provide daily care to residents in facility. Facility records reveal that facility has three scheduled work shifts for staff, a AM shift, a PM shift and a NOC shift. CONTINUED ON 9099C Unsubstantiated Records reveal that on average facility has seven to eight Caregivers in the AM shift, five to six Caregivers in PM shift and three during NOC shift. Records also reveal that facility has on average staffing ratio of 9:1 during AM shift, 11:1 during PM shift and 17:1 during NOC shift. LPA made the following observations during investigation; Facility is a Residential Care Facility for the Elderly that specializes in Memory care. Facility has capacity of 82. During investigation visit on 3/11/24 facility had a census of 51 and on todays date census of 48. During visit on 3/11/24, LPA observed 13 care staff assisting residents in facility. LPA observed that facility is divided into three neighborhoods for residents: Newport, Country Kitchen and Lido. During investigation it was revealed to LPA that staff are assigned to each neighborhood. During visits LPA observed residents relaxing in bedrooms watching TV, relaxing in common area dining rooms eating meals, and being assisted by staff in hallways & outside patio areas. Interviews with staff and residents were conducted and revealed the following, seven of seven staff interviewed stated that facility has three shifts per Caregivers and that caregivers are assigned to one of three neighborhoods inside facility. Interviews with staff revealed that five of five Caregivers stated they assist residents with Activities of Daily Living (ADL’s) such as showering, toileting, making bed’s, dressing, feeding, and transporting. All staff interviewed confirmed that no residents or family members have expressed recent concerns about the quality of care provided to residents. Interviews with Residents revealed that five of five residents stated that they had no complaints about staff members that they like the staff, staff are available when they need, and two of five residents stated that the facility is meeting their care needs. Interview with family witness confirmed that they had no issues with staffing and felt that the level of care was meeting residents needs. Based on observations made by LPA, interviews conducted, and records reviewed although the 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 following allegations: Staff are not providing adequate care to dementia residents is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Heather Younan and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 22-AS-20240305090945

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 12/08/23 regarding Resident #1 (R1). LPA met with Staff #1 (S1) Jannette Cervantes and discussed the purpose of the inspection. Administrator (AD) Heather Younan appeared via telephone. The incident report states that on 12/04/23, R1 was given 2 tabs of Tramadol in the evening instead of 1 tab, the error was noticed immediately, R1’s doctor and family were notified, and R1 was observed for any reactions. During today’s inspection, LPA toured the facility with S1, inspected the medication room, conducted a health and safety check on R1, confirmed R1 was doing well, and observed no health and safety issues. LPA interviewed AD who provided the following information. R1’s doctor advised the facility to monitor R1 closely for 2 hours and that if there was no reaction then no medical treatment would be necessary. R1 was monitored and did not have a reaction and is doing fine. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 15, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 5, 2024

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee stated they will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.

Allegation investigated: facility charging for un-needed services

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to iniiate complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Heather Younan. During the visit LPA toured facility, conducted interviews and requested pertinent documentation such as Admission Agreement, Service Plan, Physician's report, Notification letter and Routine Wellness form. LPA made observations of residents relaxing in common areas and relaxing inside bedrooms. Investigation revealed the following, Resident 1 (R1)’s recent Physician’s report dated 5/1/2023 indicated in the area of capacity for care, R1 was able to bathe and self dress requiring some assistance. Based off interviews R1 came into facility back in 2016 requiring little assistance at the time. R1’s is diagnosed with Alzheimers.Staff Interviews indicated R1 has slowly progressed the past 7 years and recently has had increased confusion resulting in additional assistance. R1’s service plan was updated on 7/12/2023. Investigation revealed that Facility conducts monthly Routine Wellness Assessments. CONTINUED 9099C . Unsubstantiated Routine Wellness Result for 6/30/2023 indicated R1 was fully independent of peri care. The Routine Wellness Results from 7/31/2023 to 9/29/23 notated resident’s assessment for peri care indicated R1 had changes to bladder incontinence and is no longer independently managed. Interviews also revealed that R1 can go to bathroom on their own however staff help assist resident with incontinence care by cleaning and changing resident after resident has had bowel movements. Interviews revealed that R1 needs assistance with wiping after using restroom. On 8/29/2023 facility sent out notification letter, notifying responsible party of R1’s change in peri care requiring incontinence care and beginning 9/1/2023 facility was implementing a charge for monthly incontinence care. Resident Billing Invoice statements indicated no incontinence charges were applied to bills for the months of June to September of 2023. Resident’s Billing Invoice dated 10/1/2023 shows an incontinence care charge was billed for the period of 9/1/23 to 9/30/23 as well as statement for care provided 10/1/23 to 10/31/23. Interviews revealed that residents account is enrolled to autopay. Invoice statements confirm resident’s account is currently paid up to date with no balances pending. Interviews revealed that at the request of responsible party, facility is in process of reimbursing resident’s account due to improper notification in person. Based on interviews conducted and documents revealed, allegation facility charging for un-needed services is deemed Unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 22-AS-20231023094358