Silverado Senior Living - Belmont Hills.
Silverado Senior Living - Belmont Hills is Ranked in the top 19% of California memory care with 1 CDSS citation on record; last inspected Mar 2026.




A large home, reviewed on public record.
Compared to 93 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Silverado Senior Living - Belmont Hills has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiency on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Silverado Senior Living - Belmont Hills's record and state requirements.
The facility has 3 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Six complaints are on file — were any substantiated, and what remediation did the facility take in response to substantiated findings?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The March 24, 2026 inspection is the most recent visit on record — can you provide the deficiency notice from that inspection and walk families through any corrective actions completed since then?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
22 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-03-24Other VisitNo findings
Plain-language summary
On March 24, 2026, the state conducted an unannounced visit after the facility reported two incidents in which two residents with Alzheimer's dementia were found undressed together—first on March 8th with no physical contact observed, and again on March 12th while engaged in an intimate act. The facility separated the residents, implemented 30-minute check-ins, updated both residents' service plans, and moved one resident to a different section of the building; no new incidents have occurred since. No violations were cited.
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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.
2026-01-05Complaint InvestigationNo findings
Plain-language summary
On January 5, 2026, a state licensing representative conducted an unannounced visit to deliver an updated version of a compliance report that was originally issued in February 2025. The administrator reviewed the amended report with the representative. No new violations or findings were identified during this delivery visit.
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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.
2025-12-29Other VisitNo findings
Plain-language summary
A state licensing inspector conducted a routine unannounced inspection on December 29, 2025, and found the facility well-maintained with clean resident areas, secure medications and chemicals, proper water temperatures, and complete staff and resident records. No violations were identified.
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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.
2025-12-29Annual Compliance VisitNo findings
Plain-language summary
On December 29, 2025, inspectors conducted a follow-up visit after an incident on December 3 in which a resident became aggressive toward staff, another resident kicked that resident's leg in what appeared to be an attempt to help the staff member, and the two residents were separated and assessed for injuries. Both residents have dementia diagnoses and documented histories of aggressive behavior; neither resident had injuries from the incident. No violations were found.
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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.
2025-10-08Other VisitNo findings
Plain-language summary
On October 8, 2025, inspectors conducted a follow-up visit after an incident on September 26 in which two residents with dementia got into a physical altercation in the dining room, with one punching the other in the face. This was the second fight between these two residents; the facility separated them, retrained staff to keep them apart, and adjusted one resident's medication. No violations were cited.
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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.
2025-09-16Other VisitNo findings
Plain-language summary
On August 26, 2025, a resident with dementia left the facility through a gate that failed to lock and was found walking on a nearby sidewalk; a staff member brought the resident back safely with no injuries. During a follow-up visit in September, inspectors confirmed that the gate lock had malfunctioned, a repair company fixed it the same day and checked all other exit gates, and no violations were cited. The facility re-keyed all gates to prevent similar incidents.
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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.
2025-08-05Other VisitNo findings
Plain-language summary
On August 5, 2025, state licensing staff conducted an unannounced visit to deliver an immediate exclusion letter, which means a staff member was prohibited from working at the facility. The administrator was notified of the exclusion in person and given a copy of the letter.
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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.
2025-07-31Other VisitNo findings
Plain-language summary
On July 31, 2025, the state conducted a follow-up visit to investigate an incident from July 8, 2025, in which a resident reported that a staff member pushed them against the wall. The facility investigated the allegation but could not find witnesses to substantiate what happened; the resident was diagnosed with dementia and had no history of making similar accusations against staff. No violations were found, the staff member received additional training, and the facility reassigned them to work in a different area away from the resident.
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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.
2025-07-31Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that a resident was neglected and became dehydrated, but the investigation found no evidence to support this claim. Staff confirmed they were aware of the resident's history of dehydration and took steps to monitor their water intake, including providing a water bottle to track daily consumption. The facility's documentation and interviews did not substantiate the neglect allegation.
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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.
2025-06-04Other VisitNo findings
Plain-language summary
On June 4, 2025, state licensing staff conducted an unannounced visit to deliver exclusion letters for two staff members, meaning they are prohibited from working at the facility. The Director of Health Services received the letters and reviewed them with the licensing analyst.
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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.
2025-05-27Annual Compliance VisitNo findings
Plain-language summary
On April 27, 2025, a caregiver hired through a third-party vendor was found holding a resident's door knob to prevent the resident from leaving their room; staff immediately intervened, and the facility terminated the caregiver and reported the incident to authorities. During a follow-up visit in May 2025, inspectors found that the resident, who has advanced dementia, was being treated with a psychiatrist and had new medications started to address recent behavioral changes after a previous medication was discontinued. No violations were cited.
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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.
2025-02-25Other VisitNo findings
Plain-language summary
During a visit, inspectors found that staff did not call 911 after a resident fell and complained of pain in the morning; instead, the facility waited until 5:30 p.m. when the resident began moaning and could not move their legs to seek hospital care, at which point the resident was found to have a hip fracture. The facility was assessed a $500 civil penalty for failing to seek medical attention promptly, with additional penalties still being determined. A separate allegation that the facility failed to notify the resident's family was found to be unfounded.
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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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.
2024-12-03Other VisitNo findings
Plain-language summary
A routine annual inspection was conducted on December 3, 2024, and found the facility in good order: resident rooms and common areas were clean, medications and hazardous chemicals were properly secured, staff training records were current, and emergency procedures including fire drills were being followed. The inspector also verified that water temperatures, lighting, and overall living conditions met safety standards.
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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.
2024-03-15Other VisitNo findings
Plain-language summary
On March 11, 2024, a resident with Alzheimer's disease was found outside the facility's perimeter twice—once near the parking lot and again near a neighboring picnic area—despite all gates being locked and secure. Staff immediately searched for and returned the resident each time, and the facility responded by assigning a dedicated caregiver, moving the resident to an area with more staff presence, and conducting regular safety checks. No violations were cited, and the facility's investigation found no evidence of equipment failure or tampering with the gates.
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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.
2024-02-16Annual Compliance VisitNo findings
Plain-language summary
This is a follow-up case management visit on a substantiated 2019 complaint investigation. The facility failed to accurately assess a resident's fall risk despite multiple falls in 2018, did not implement appropriate safety measures, and did not inform the resident's doctor about the falls—resulting in the resident falling again in March 2019 and sustaining a hip fracture that required surgery. The state issued a $10,000 penalty for this violation that caused serious bodily injury.
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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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.
2024-01-31Other VisitNo findings
Plain-language summary
On January 31, 2024, inspectors conducted a routine unannounced inspection of the facility, touring all resident neighborhoods, kitchens, bathrooms, and administrative areas. They found the facility clean and well-maintained, with proper medication storage and security, complete staff and resident records, working fire safety equipment, and appropriate temperature and lighting throughout. No violations were found.
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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.
2023-12-19Other VisitType A · 1 finding
Plain-language summary
On December 10, 2023, a staff member found a resident touching another resident's chest area; this happened because the first resident's one-on-one caregiver left without notifying staff, which violated facility protocol requiring notification before breaks. This was the third such incident involving the first resident in a month. The facility failed to provide the one-on-one caregiver with orientation or training about break procedures, resulting in the resident being left unattended.
“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.”
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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.
2023-12-06Other VisitNo findings
Plain-language summary
During a follow-up visit on December 6, 2023, inspectors reviewed two incidents from November in which a resident with Alzheimer's disease touched other residents inappropriately; the facility separated the residents immediately both times, assigned a dedicated one-on-one caregiver, consulted the resident's physician about medication adjustments, and reported having no further incidents since those measures were put in place. The inspector found no violations and noted the resident was observed in the dining room with their assigned caregiver during the visit. The facility planned to continue monitoring and to hold a meeting with the resident's physician and family to reassess the resident's care plan.
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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.
2023-09-29Other VisitNo findings
Plain-language summary
An unannounced case management visit was conducted on September 29, 2023, during which a state licensing analyst delivered an immediate exclusion letter to the facility, prohibiting a specific employee from working there. The administrator and health services leadership were present when the letter was delivered and provided with a copy of the report.
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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.
2023-09-07Other VisitNo findings
Plain-language summary
On September 7, 2023, the state conducted a follow-up visit after the facility reported two incidents involving a staff member on August 25 and July 25, 2023—one allegation that the staff member threw tea on a resident, and another that the staff member made hand contact with a resident. The staff member was suspended immediately and terminated on August 30, 2023; the facility notified police, the ombudsman, and other required parties, and no deficiencies were cited during the inspection.
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On September 7, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit at the facility to follow up on an incident that was reported on 8/28/2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reported on 8/25/2023, Staff #1 (S1) reported to Administrator that he/she observed Staff 2 (S2) throw a cup of tea on Resident 1 (R1). In addition, S1 reported that he/she observed S2 on 7/25/2023 make contact with S2's hand to Resident 3 (R3). During the visit, LPA discussed incidents with the administrator and director of health services. According to the interviewed staff, there were not witnesses for the two incidents being reported by S1. S2 was immediately suspended on 8/25/2023 and later terminated on 8/30/2023. Belmont Police, Ombudsman and all required parties were notified. Administrator to send facility's internal investigation records to LPA by 9/8/2023. No deficiencies are cited during visit. LPA to conduct a follow up visit if required. Report is reviewed with Director of Health Services and a copy is provided.
2023-08-18Other VisitNo findings
Plain-language summary
On August 18, 2023, inspectors conducted an unannounced follow-up visit after a resident was bitten by a dog on August 10, 2023, resulting in a small wound on the resident's finger with no reported pain. The inspectors reviewed the dog's vaccination records (all current), the facility's pet policies, and interviewed staff; they found no prior biting incidents with this dog, which was subsequently returned to an adoption center, and no violations were cited. The facility has policies in place allowing both facility pets and resident-owned pets as part of quality of life programming.
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On August 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an incident that was reported to CCLD on 8/17/2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reported on 8/10/2023, Resident 1 (R1) was bitten by a dog. Blood was noted on right middle finger, however R1 denied pain. During the visit, LPA interviewed the administrator, requested copies of the dog's vaccination records, reviewed facility policies and procedures regarding pets, observed blank facility admission agreement and reviewed a copy of resident handbook regarding pets at the facility. According to the administrator and director of health services, there were no prior biting incidents at the facility with this specific dog. The dog was returned back to the adoption center after the incident. LPA reviewed resident handbook and policies and procedures regarding pets at the community. Based on the resident handbook reviewed, it indicated that the community has pets to promote resident's quality of life. In addition, the facility handbook also indicates that residents are welcome to bring their pets as well. Furthermore, LPA reviewed the dog's vaccination record and all shots are up to date. No deficiencies cited during the visit. Report is reviewed with Director of Health Services and Administrator and a copy is provided.
2023-08-02Other VisitNo findings
Plain-language summary
On August 2, 2023, a state licensing representative made an unannounced visit to investigate incidents reported on July 18 involving interactions between a staff member and three residents. The facility provided documentation and met with the licensing representative, and no violations were cited. The findings were reviewed with the administrator.
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On August 2, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCL on 7/20/2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. The Licensee reporting on 7/18/2023, a staff member (S1) reported 3 separate incidents that occurred between Staff 2 (S2) and 3 different residents. During the visit, LPA collected documentation. No citations are issued at this time. Report is reviewed with administrator and a copy is provided.
19 older inspections from 2021 are not shown in the free view.
19 older inspections from 2021 are not shown in the free view.
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