Silverado Senior Living-berkeley

While investigating a complaint (Control # 15-AS-20211124153927), and upon review of Unusual Incident Report (UIR), Licensing Program Analyst (LPA) Delmundo learned that the UIR for incident that happened on October 29, 2021 was submitted to the Department on December 7, 2021. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with Jeff Emoruwa. Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.

On 10/21/2021 at 03:50 PM, Licensing Program Analyst (LPAs) L. Holmes and L. Francisco arrived unannounced to co3duct Infection Control Inspection. LPA met with Administrator, Robert Snee and Jeff Emoruwa Director of Health Services and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 03/21/25 around 01:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an infectious outbreak. LPA met with Administrator (ADM) Jeffrey Emoruwa, and explained the purpose of the visit. On 03/12/25, S1 informed LPA that fifteen (15) residents were manifesting gastrointestinal (GI) symptoms that included diarrhea, and vomiting. To date, the facility has closed communal dining. All residents are on Bananas, Rice, Applesauce, and Toast ( BRAT) diet, and are offered clear fluids every 2 hours. Visitors and staff has been informed to wear PPE while caring for these residents and to wash their hands with soap and water regularly. Local Public Health (PH) department provided advisories to be posted at the main entrance to advise all incoming visitors and staff. PPE is available at the entrance, sufficient and recommended for all. Environmental services inspected kitchen and negative of any infectious disease. PH estimates that Tuesday, 03/25/25, all should be clear at the facility. A copy of this report provided to the Jeffrey Emoruwa, Administrator

On 10/16/2025 at 1:00 PM, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez conducted a case management visit as a result of a self-reported incident report received 10/10/2025. LPA met with the Administrator Michelle Neumann. It was reported that R1 was found after an unwitnessed fall. LPAs reviewed R1's care plan, physicians report and toured the facility. R1 returned back to the community and was re-accessed for any changes in condition. LPAs reviewed a random sample of staff records and found that all their training's were up to date. Exit interview conducted and a copy of this report provided.

On 03/05/2025 around 12:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Required 1 Year inspection. LPA met with Jeffrey Emoruwa, Administrator and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#7016762740 ) that expires on 08/05/26. The facility’s fire clearance was approved for ninety (90) non-ambulatory residents; sixty-two (62) may be bedridden. Upon arrival LPA observed two (2) staff attending to the residents that were interacting and congregating in the common area of the facility. LPA, ADM and S5 toured the facility including, but not limited to bathrooms, shower room, common areas, medication room/nursing station, laundry room, dining areas and courtyard. The facility consists of individual apartments style rooms housed by the residents. Residents were exercising, playing the piano and listening to music. All outdoor and indoor passageways were free of obstruction. There were not any bodies of water. A comfortable temperature was maintained at 72 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 113 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products were available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C. 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 ...continued from LIC9099. The facility is masking per City of Berkeley's Public Health recommendations. Smoke detectors and carbon monoxide units were in operating condition during visit. Fire extinguishers were observed full and last inspected 05/13/2024. Emergency Disaster Plan is updated. Safety drill was conducted last quarter by Safety First. Five (5) staff records were reviewed, and all staff have criminal record clearances. Seven (7) residents records were reviewed and are complete. The following forms are to be updated and submitted to CCLD: -Resident Roster -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) (Reviewed) -Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Jeffrey Emoruwa, Administrator

On 03/21/25 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day complaint investigation and a Health and Safety inspection. LPA met with Administrator (ADM) Jeffrey Emoruwa and explained the purpose of the visit. LPA toured facility including, but not limited to the shared bathroom, common area, outdoor and indoor areas; indoor and outdoor passages were free of obstruction. Hot water temperature in the shared restroom was measured at 110.4 degrees F. Resident's are housed in individual apartment style rooms with adequate lighting in each room for the safety of residents. Resident rooms were observed to be clean and fully furnished. Facility purchases food 2-3 times a week to maintain 7-days of non-perishables, and 2-days of perishable foods. Resident's medications are kept locked in a medication cart located in the medication room on the 1st and 2nd floor. Smoke and Carbon monoxide detectors observed operational. Fire extinguisher was observed to be full and last serviced on 05/14/2024. There are no accessible bodies of water observed. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to Jeffrey Emoruwa, Administrator.

On 04/07/2026 at 2:00PM, Licensing Program Analysts (LPAs) T Syess-Gibson and L. Hall conducted a case management as a result of information received during complaint visit 15-AS-20260401130802. LPAs met with Morgan Whinery, Administrator, and explained the purpose of the visit. While conducting the complaint investigation LPAs was informed by S1 that the incident report for R1's hospitalization was not submitted to CCLD within seven days of the occurrence. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of this report and appeal rights provided.

On 03/05/25 around 10:00 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding two (2) Unusual Incident Reports (UIRs). LPA was greeted by the Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting. ADM arrived about ten (10) minutes later. On 02/21/25, LPA received an email from ADM reporting 2 staff made physical contact with 2 residents on 2 different occasions. The facility became aware of the incidents evening on 02/19/25, and the investigation is still in progress. Staff (S1, S2) were suspended on 02/19/25 pending the results of the investigation; residents involved were (R1, R2). S4 alleged that S1 made contact to R1's left cheek while trying to stop R1 from be being agitated, throwing glass and trying to hit at S1. S4 stated that the incident happened in the dining area about a month ago (01/2025) S3 alleged that S2 slapped R2's forearm in an effort to prevent R2 from placing his/her hands inside their own briefs. S3 stated that the incident occurred about 2 months ago (12/2024) in R2's bedroom. Human Resources conducted a one (1) day investigation on site, and 1 day of calling for interviews; four (4) additional caregivers and 2 nurses were assigned to the facility to assist. W1 interviewed ADM also. S1 resigned prior to completion of the investigation. At this time, the facility's investigation is inconclusive. Exit interview conducted and a copy of this report provided to Jeffrey Emoruwa, Administrator.

...continued from LIC9099. In addition, statements were obtained from Staff (S1, S2, S3, S4, S5, S6) and Witnesses (W1, W2, W3, W4, W5). The allegation occurred on 03/10/25 around 06:48 AM. S5 assisted R1 with ADL’s, charted details of bruises on R1’s body and reported the incident to S1. S1 stated that he/she had never seen any bruises like this before on R1’s body and contacted 911. BFD arrived on site at the facility. BFD obtained urines samples, reported R1’s physical and mental condition BPD. On 03/10/25 at 06:50 PM, BPD responded to BFD personnel; W1 was present to assist with R1’s language translation. It was alleged that staff (W2) sexually assaulted R1. Due to R1’s diagnosis of Dementia, R1 was not able to provide details or additional information about the bruises and R1’s statements did not consist of sexual assault. W2 denied sexually assaulting R1 and stated that he/she had not observed any bruising or had any sexual contact with R1. W2’s last contact with R1 was through W2’s shift on 03/09/25 that ended around 10:45 PM. W2 was not employed by the facility, instead by R1’s family. On 03/09/25 at 05:40 PM, S5 and S6 provided care to R1 with ADL’s and toileting. S6 did not observe anything unusual or bruising on R1. S7 stated and reported on R1’s Progress notes dated 03/10/25 at 07:57 AM that R1 slept for 4.5 hours and noted R1 using his/her hands to hit his/her legs; it was very loud, and the noise was heard at the nursing station in the next room #28, R1 resided in room #29. PRN Codeine and Olanzapine were given to R1 at 3:09 AM, noted effective, and no abnormal findings were reported by W2. Records and interviews from S1, S2, S3, W1, W2, and W3 revealed that R1 was a fall risk, there was no evidence of sexual assault and no determination for the cause of bruises on R1. Based on all the information obtained, there was not enough evidence to conclude that R1 was sexually assaulted; therefore, the allegation is unsubstantiated. A finding that the complaint 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. Exit interview conducted and copy of this report provided to Michelle Neumann, Senior Administrator Specialist.

On 10/08/24 around 01:45 PM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding reporting requirements. LPA met with Durga Acharya, Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting. On 09/13/24,LPA L. Holmes received an email from LPA L. Sampair with COVID-19 report and death reports that were provided to licensing from the facility. Five (5) of the ten (10) reports sent by Silverado Berkeley were late and did not meet the regulatory guidelines for notifications and reporting. LPA requested that ADM advise CCLD when the facility has been cleared of COVID-19 so that a case management could be conducted for late reporting of the deaths and incidents that had occurred during the month of August. On 09/16/24, ADM advised that the facility did not have any COVID-19 cases and essentially the facility was clear. ADM stated that he’d speak with their Director of Health Services to find out more about the late reporting. Based on information obtained the deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights, and copy of this report provided to Durga Acharya, Receptionist .

...continued from LIC9099 UNSUBSTANTIATED : Facility staff did not ensure that resident's oxygen canister was full. Facility staff did not implement resident's doctor's orders. Facility staff did not administer resident new prescription medications timely. For the allegation, facility staff did not ensure that resident's oxygen canister was full. LPA interview S1 and S2 that both stated R1 received oxygen from a concentrator and canister daily. On 03/31/23, R1 was in the common area when W5 arrived who stated that R1’s Oxygen Saturation (SO2) was about 70% which was unacceptable and life threatening. LPA asked were the paramedic’s contacted; W5 stated, “No, I happen to catch it in time” W5 did not provide LPA with any documentation for R1’s OS and said that R1 would be moving after the incident. S1 provided LPA with R1’s Service Plan Details, charted eMar and Vital Signs Trends Report for R1’s SO2. R1’s SO2 remained constant on 03/31/23; at 6:22 AM 96% was recorded, at 1:26 PM 96% was recorded, and at 9:03 PM 97% was recorded. W5 did not provide any documentation of R1’s SO2 levels. On 03/31/23, S2 provided R1 with a replacement cannister and S1 stated that it would be impossible for R1 to walk or breathe if R1’s SO2 was at 70%. Records reviewed revealed that R1’s doctor’s orders were being followed. Oxygentank, R1's SO2 distributor, delivered twelve (12) canisters on 03/02/23 and twelve (12) on 03/16/23. W1 did not return LPA’s phone calls prior, during or after the investigation on 05/01/2023 to confirm R1’s new prescription that was alleged to not being administered. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview and a copy of this report provided to ADM.

After the incident, R1’s wife requested a meeting with S1 and S2 together with two other individuals who are not related to R1 but have family members living at the facility. During the meeting, plans and procedures were discussed on how to make sure that R1 is safe while living at the facility. And part of the agenda was to discuss R1’s medications. Based on interviews conducted, S2 states that it was an oversight on the part of the facility to allow other individuals who are not involved in R1’s care to be part of the meeting since the purpose of the meeting is to address R1's condition and there is always a possibility of disclosing R1’s personal information. Based on interviews and records reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are substantiated. California Code of Regulations, Title 22 are being cited on the attached Lic 9099D. Exit interview was conducted with Emoruwa and Appeal Rights was provided.

...continued from LIC9099 LPA reviewed records and interviewed S1, S2, W2, and W5 which revealed that W1 is the Fiduciary and Responsible Party for R1. W2 stated that W1 refused to give him/her information about R1. S1 stated that W1 did not give notice that R1 was moving; W1 had an issue with W2 and did not want W2 to be allowed to visit although the facility had not had any problems with W2. W5 alleged that there had been emotional, medical, and financial abuse along with the death threats toward R1 from W2. S2 stated that he/she did not have knowledge of R1’s whereabouts and W1 just started gathering things to move R1 on 04/07/23. W1 did not return LPA’s phone calls prior, during or after the investigation on 05/01/2023. To date, W1 did not send any additional notification to S1 regarding R1's relocation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report provided to ADM.

On 03/08/2024 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/26/2024. LPA met with Director of Health Services(DHS) and explained the purpose of the visit. The incident report received stated that Resident (R1) eloped from the south side exit door of the facility at 7:17PM on 02/24/24. Staff (DHS) reviewed security footage and confirmed R1 eloped at 7:17PM that night. Staff reset the exit door alarm at 7:19PM and did not immediately look for missing R1. Records review of R1's physician's report dated 06/24/22 indicated that R1 is not able to leave the facility unassisted. Incident report dated 02/26/24 showed that R1 was noted missing by staff at 7:30PM when caregiver went to look for R1 to assist him to bed. At 7:43PM, R1 was reportedly found by a concerned citizen who called the facility with the location of R1. Staff returned R1 safely back to the facility at 8PM on 02/24/24. DHS stated staff notified her of R1's elopement incident at 8:17PM on 02/24/24. LPA obtained a copy of the staff roster, resident roster, resident's (R1) physician's report and progress notes for the month of February 2024 during the visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided to DHS.

On 05/01/2023 at 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual required inspection. LPA met with Jeff Emoruwa, Administrator and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#604 9144740) that expires on 08/05/24. The facility’s fire clearance was approved for ninety (90) non-ambulatory residents; sixty-two (62) may be bedridden. Upon arrival LPA observed two (2) staff attending to residents that were playing BINGO and monitoring the facility. LPA and ADM toured the facility including, but not limited to bathroom, kitchen, common areas, medication room, nursing station, laundry room, dining area and co ur t ya rd. The facility consists of individual apartments housed by the residents. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 110.5 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene product available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C. 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 ...continued from LIC9099. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 05/02/2023. Emergency Disaster Plan is updated. Safety drill was last conducted 03/2023 and are rotational between AM and PM schedules monthly. Five (5) staff records were reviewed, and all staff have criminal record clearances. Five (5) residents records were reviewed and complete. No deficiencies cited during visit. Update resident files with safeguards for property/valuables forms by 05/15/2023. Exit interview conducted and a copy of this report provided to ADM.

On 12/02/21, LPA interviewed Jeff Emoruwa, previous Executive Director Robert Snee and staff (S2 and S3). Jeff Emoruwa stated he was not at the facility when the incident between R1 and R2 happened but it was reported to him. Robert Snee stated he was at the facility that early morning but he did not witnessed when it was happening. Snee indicated it the first time R1 exhibited aggressive behavior. S2 stated she did not witnessed the incident but the front desk person (S4) who witnessed it called, and she and the facility LVN went to the lobby where the incident took place. They separated the residents. S2 stated R1 is a nice person and it was the first time R1 exhibited aggressive behavior. Staff were told to monitor R1 and R2. S3 indicated she did not witness the incident, and R1 and R2 were not assigned to her. LPA was not able to obtain information from R1, R2 and S4. On this day, 3/23/23, LPA interviewed S1 and S5. S1 stated he does not remember exactly what happened but with residents with diagnosis of dementia, incident can happen so fast, and when it happens, they separate the residents. He assess and determines what are the triggers to the behavior. If there's injury, they call 9-1-1 and notify the resident's primary care physician and responsible person. S5 stated when incident between residents happen, they separate the residents and call the facility LVN to assess. If there's injury, they call 9-11 right away. Based on all information ga thered, and LPA unable to obtain information from R1, R2 and S4, the allegation of resident (R1) pushed another resident (R2) while in care is closed as unsubstantiated. A finding that the complaint 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. No citation issued. Exit interview conducted, and copy of this report provided.

On 01/19/23 at 10:15 AM, Lic ensing Program Analyst (LPA) L. Holmes conducted an unannounced subsequent complaint visit to deliver the findings for allegations and complaint received on 12/24/2020 15-AS-20201224083234 for facility #0191920079. L PA explained the purpose of the visit with Jeff Emoruwa, Administrator. Exit interview conducted. A copy of this report provided to Jeff Emoruwa, Administrator

On 09/30/22 at 03:05 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one receptionist upon entry and explained the purpose of the visit. Jeff Emoruwa, Director of Health Services was present at the front desk. Facility has a COVID-19 mitigation plan on file. LPA obtained a resident roster and staff roster. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, kitchen, and storage. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Administrator posted 20 seconds hand washing signs in the kitchen and continues to maintain isolation carts for infection control. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally stored and located inside the facility that is accessible to Care Staff. Hot water temperature in the shared residents' bathroom was measured at 114.5 degree Fahrenheit (F) and the facility's temperature was 72 degree (F). Fire extinguisher was observed full and last inspected on 03/22/2022. Smoke/Carbon Monoxide detectors were observed operational. The following forms are to be updated and submitted to CCLD: -LIC500 Personnel Report (Reviewed) -LIC308 Designation of Administrative Responsibility -LIC610E Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) (Reviewed) Exit interview conducted and a copy of this report provided to Jeff Emoruwa, Director of Health Services.

Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an case management regarding an incident report for R1. LPA met with Jeff Emoruwa, Director of Health Services. During the course of the visit LPA interviewed S1, S2 and S5. LPA collected the following documents: resident roster, physician's report; ID and emergency information, behavior mapping, comprehensive assessment and service plan, care conference sheet, and resident appraisal. LPA requested staff roster, and police report for R1. UIR, records and interviews revealed that R1 eloped, R1 was not a flight or elopement risk. Contractors were on site and the alarm system had been disarmed by S3. S3 asked S2 to close the doors but was not aware that the alarm system had not been armed/reset. S1 stated that S2 is a new employee and the alarm system has two different codes that need to be activated. R1 wandered about two blocks away to a synagogue on Jefferson St and Berkeley police were called by an unknown person. Berkeley Police reported to S5 that R1 appeared confused, was in their custody, and returned R1 to the facility appearing uninjured. S1 completed in-service training with Plant Operations and Care Staff; all staff are responsible for disarming/arming the alarm system themselves and verifying it's operational. No deficiencies cited, exit interview, and a copy of this report provided to Jeff Emoruwa.

On 12/28/2021 Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM ) Y. Flores-Larios arrived unannounced to conduct a case management visit. LPA and LPM met with Robert Snee, Administrator and explained the purpose of the visit was to gather more information regarding incident reports received on 12/06/2021 involving three different residents. LPA conducted interview with Administrator and reconfirmed actions that the facility is taking to ensure residents safety. Requested corrected incident report to be sent to CCL. No deficiency cited Exit interview conducted with Jeff Emoruwa, Director of Health Services and copy of this report provided.