Silverado Brea Llc.

LPA was unable to interview R1 due to not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed an in service of updated staff training dated September 16, 2025, that covered topics of preventing bruising/pressure injuries. Regarding the facility allegation of medications are accessible to residents in care and facility is falsifying medication log revealed the following: It was alleged that staff are leaving medications in a room unattended making the medication accessible to residents in care and that facility staff threw away medication after a resident refused to take it, but told staff that it had been administered. Interviews with three of three staff revealed that the facility nurse is the only one that passes medications and marks off the medication log and that they stand there and ensure the resident takes their medications before moving on. Three of three staff could not recall a time where medications were ever accessible to residents in care or when the medication log had been falsified. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed a medication security policy that was reviewed and signed by facility staff on March 27, 2025 and April 1, 2025. LPA reviewed resident medication and observed it to be administered according to physicians orders at the time of the investigation using the facility electronic medication administration record. Regarding the facility allegation of residents hygiene needs are not being met revealed the following: It was alleged that residents were not given showers for three weeks. Two of three staff informed LPA that when a resident refuses to take a shower, they will try again later. If the resident keeps refusing, they will try again on the next shift. Two of three staff informed LPA that they will keep asking the resident, but will not force them to take a shower. LPA did not observe shower logs for residents in care. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed staff training covering bathing a person with dementia last done in the year 2024 for three of three staff. Regarding the facility allegation of residents bedding is left soiled for a long period of time revealed the following: It was alleged that facility staff left Resident #2(R2) in their soiled bed for three weeks. LPA reviewed a physicians report dated January 1, 2023, stating that R2 was diagnosed with dementia, does not require continuous bed care, did not have bladder or bowel impairment, was unable to communicate their needs, was able to care for their own toileting needs and was considered non ambulatory. Two of three staff informed LPA that residents are checked for brief changes every two hours unless needing a changing sooner. Two of three staff informed LPA that caregivers are able to change residents sheets even if they are still in the bed. Two of three staff informed LPA that R2 was difficult to change, but the staff never left them soiled for an extended period of time. Continue on 9099C 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 The Department attempted to interview R2, but they could not confirm or deny the allegation. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed a staff in-service training that was conducted on September 16, and September 29, 2025, covering topics such as bed making, perineal care, and bowel movement protocol. LPA observed residents to be out of their rooms and appeared to be cleaned. LPA did not observe a smell throughout the facility due to residents hygiene needs not being met or residents being left soiled for a long period of time. Regarding the allegation of facility staff did not provide adequate supervision resulting in a resident consuming another resident's medication revealed the following: It was alleged that Resident #3 (R3) drank Resident #4(R4) medication that was crushed and put in their drink. LPA reviewed a physicians report dated November 4, 2021, stating that R3 was diagnosed with dementia and was able to feed themselves. LPA did not observe an updated physicians report for R3. LPA reviewed a physicians report dated November 21, 2022 for R4 stating that R4 was diagnosed with dementia and is able to feed themselves. LPA did not observe an updated physicians report for R4. Three of three staff informed LPA that they do not walk away from the resident until all the medication has been consumed to ensure that another resident does not pick up their cup. One of three staff informed LPA that R2 is unable to drink unassisted, so staff would help them drink the juice with their medication. The Department attempted to interview R3 and R4 and they could not confirm or deny the allegation. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed updated staff medication training dated June 8, 2025, and October 29, 2025, for two of three staff. One of three staff does not do medication distribution in the facility. LPA did not observe medications accessible to residents at the time of the investigation. LPA observed the medication room and the medication cart to be locked on both of the facility floors. Regarding the facility allegation of resident was left in the same clothing for a long period of time revealed the following: It was alleged that Resident #5(R5) was left in the same clothing over an entire weekend without being changed. LPA reviewed a physicians report dated April 27, 2022, for R5 stating R5 was diagnosed with dementia and was able to dress/groom themselves. LPA did not observe an updated physicians report for R5. Two of three staff informed LPA that R5 wore similar clothing everyday which included a tshirt and levi jeans. Two of three staff informed LPA that R5 looked the same everyday due to their clothing being so similar. LPA was unable to interview R5 due to them not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed three of three staff have resident personal rights training completed in 2024. Continue on 9099C 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 Based on information gathered, interviews and record review, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided at the time of the investigation.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Tana McMillon, Regional Vice President of Operationsr at 12:30pm and explained the purpose of the visit. The facility is a two-story building with a capacity of seventy non-ambulatory residents; of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of forty-three residents in care. During today's visit, LPA toured the facility and inspected the physical plant . LPA tested hot water temperatures in five of five resident bathrooms. The hot water temperature measured between 107.9 and 113.0 d egrees Fahrenheit . Resident apartments had the required furnishings and were clean with no hazards observed. The fire sprinklers, smoke alarms and carbon monoxide detectors are tested annually and were tested on October 17, 2024. The next test is scheduled for November 11-12, 2025. The Director of Plant Operations (DPO) will email LPA with results from the November 11-12, 2025 inspection. There are fourteen fire extinguishers throughout the community and they were charged and were serviced on May 21, 2025. The facility’s last fire drill was conducted on September 7, 2025 and evacuation chairs were observed in stairwells. LPA and DPO tested the delayed egress doors in the Birch neighborhood and egress door released after thirty seconds. (Continued on LIC 809-C) 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 LIC 809) LPA inspected the kitchen food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand . The walk-in refrigerator had a variety of fruits and vegetables and a temperature log is updated daily. The kitchen is secured with a keypad so only staff are able to enter. Knives are secured in the kitchen. Emergency supplies were in the storage room and water is stored outside. Hazardous chemicals are stored in a locked storage room. The Birch Community has a meditation room/theater and residents were observed listening to soothing music in the common area. There is a courtyard where residents and family members were visiting and there were shaded seating areas. The were no hazards obstructing hallways or walkways. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. First Aid Kits were observed in the medication rooms with the required elements. LPA pressed a resident pendant and staff came within five minutes to assist. LPA reviewed five of five staff training and fingerprint record s and reviewed five of five resident records . LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that the administrator has a current administrator certificate which expires on November 18, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Regional Vice President of Operations and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to amend findings for Complaint Control # 22-AS-20250819122622; which was delivered on August 28, 2025. LPA was greeted and granted entry by the receptionist and met with Administrator (AD) Ashiman Gill and explained the purpose of the visit. LPA explained to AD Gill that the complaint finding of Unsubstantiated is being amended to Unfounded. An exit interview was conducted with AD Gill and a copy of the amended findings and this report was provided to the facility.

(Continued from LIC 9099) The Physician's Report dated 1/17/2025 states R1 has a diagnosis of dementia. Upon questioning, R1 could not recall a recent fall that occurred. R1 stated they enjoyed their breakfast but could not recall what they ate for breakfast. LPA interviewed two of two witnesses, four of four staff and Resident #1 (R1) regarding the fall incident. Two of four staff members were present at the time of the fall. One staff member witnessed R1 sitting on the bed and then R1 losing their balance and falling to the floor. The other staff member heard the fall and headed to the area and the nurse immediately followed. LPA reviewed video footage and obtained photos of time stamps regarding the incident. Staff interviews indicated R1 had a witnessed fall at 7:42am. Camera footage shows staff member stepping out of the room and within a minute's time, a second staff member and then the nurse are observed going into the room. Staff notified Responsible Party (RP) and paramedics were on-site by 7:57am. LPA reviewed the documents and an updated assessment was conducted on August 13, 2025 regarding R1. An Unusual Incident Report was filed with the Department by the facility and resident returned on same day. Upon return, a personal 1:1 caregiver was provided to observe R1 from 8pm to 8am and Behavioral mapping of nighttime activities was completed. Based upon LPA observations, interviews, records and video review the allegation that a Resident fell due to lack of care and supervision is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Ashiman Gill, Administrator, and a copy of this report was provided to the facility. ****THIS IS AN AMENDED REPORT****

(Continued from LIC 9099) An Unusual Incident Report was received by the Regional Office on Monday, July 14, 2025 regarding the medication error. Per Unusual Incident Report, "R2 was placed under close monitoring protocol, with vitals assessed regularly throughout the evening and overnight. No adverse effects were observed." It is noted that R2 remained stable, alert and could communicate needs. A Nurse Practitioner visited R2 the next morning and resident remained stable and at baseline. Therefore, the allegation that staff are not following reporting requirements is Unsubstantiated. LPA reviewed R1,R2 and Resident #3 (R3)'s electronic Medication Administration Records and reviewed resident files. LPA also audited the med cart for all three residents and meds were on cycle, and eMARs were properly initialed. For the resident, R2, who received the wrong medication, it was documented by the nurse, "DNG" which stands for Did Not Give for PM meds. LPA spoke with Nurse regarding medication destruction procedures and meds are destroyed within 24 hours, if not given. Thus there were no extra medications in the med cart for R2. The allegation that staff falsified residents' records is Unsubstantiated. LPA interviewed Residents #1 and Resident #2 while conducting a health and safety check. LPA also interviewed one witness and five of five staff members regarding the incident on the evening of July 13, 2025. 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 allegations: Staff are not following reporting requirements and Staff falsified residents' medication records are Unsubstantiated. An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was provided to the facility.

Licensing Program Analyst (LPA) Rose Ruppert attempted an unannounced visit on January 15, 2025 at 4:10pm to conduct a Case Management visit. The Regional Office received an Unusual Incident Report on January 10, 2025 regarding a resident elopement. During today's visit the Executive Director (ED) was at a sister community and the Director of Health Services (DHS) was on a scheduled phone call for a family meeting. LPA will return to conduct the Case Management visit at a later date. LPA returned on this date to conduct the Case Management visit. LPA was greeted and granted entry by the receptionist and met with Executive Director (ED), Ashiman Gill. LPA explained the purpose of the visit and requested the following documents: Staffing schedule for Thursday, January 9, 2025, Resident Emergency and Identification Form, Physician's Report and Appraisal. LPA also obtained staff Elopement Drill In-service documents and nurses notes. ED Gill showed LPA the courtyard exit that led to the resident elopement. Resident exited the courtyard door and was visually sighted by the front desk receptionist. Within minutes the Office Service Manager (OSM) and Director of Residents and Engagements (DRE) were with resident and DRE redirected resident back into the community, with assistance from other staff members. The OSM and ED initiated the community's elopement procedures and all staff checked exit doors and did a resident head count to make sure all were secured. Responsible party was notified and the resident was assessed ED provided an Elopement Drill In-service to all staff and it was determined an associate had not completely closed the exit door; while taking out trash and was given associate counseling. The courtyard exit door will now remain locked, with management doing checks daily to make sure the door is closed. Staff were told not to use the courtyard exit to perform job duties and a loud audible alarm was installed on the door, to alert staff if the door is open, the very next day. (Continued on LIC 809-C) 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 LIC 809) LPA observed resident participating in group chair exercise and enjoying the workout. Afterwards LPA spoke with resident, who stated, "I'm fine. Everything is okay." LPA thanked the resident for the interview. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to the facility at 1:45 pm. LPA was greeted and granted entry by the Concierge and met with Ashiman Gill, Administrator (AD) and LIbbie Retts, Director of Health Services (DHS) and stated the purpose of the visit LPA interviewed three of three staff members regarding the Unusual Incident Report received in the Regional Office on December 23, 2024. LPA interviewed two of two resident family members. LPA requested the following resident records: Identification and Emergency Information, Appraisal, Physician's Report, Physician Order Review, and Incident Progress Notes. LPA also requested staff files and the staffing schedule for care staff and engagement staff for December 20, 2024. LPA was also shown video footage of the incident. Based on the interviews and observations made during today’s visit, LPA will need to further investigate the incident. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge. During today’s visit, LPA met with Tana McMillon, Administrator (AD) and LIbbie Retts, RN, MSN, Director of Health Services (DHS). The facility is a two story building with an approved fire clearance of seventy non-ambulatory residents of which twenty-five may be bedridden . The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of thirty-seven residents in care. At 8:40 AM LPA toured the facility and spoke with residents in the dining room after breakfast. Staff members were escorting residents to the common areas and to convert the dining room for residents to have a scheduled fitness activity at 9:30 AM. LPA noted the activity would be a zumba class. LPA inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on the delayed egress exits in the Birch neighborhood. The hot water temperature measured between 107.0 and 109.4 degrees Fahrenheit and all smoke detectors were operational and were recently tested by Smart Systems Technologies on October 17, 2024. Fire extinguishers throughout the community were charged and serviced on April 2, 2024. The facility’s last fire drill was conducted on October 3, 2024 by Fire Safety Services, Inc.and are done quarterly. LPA observed one of two elevators were out-of-order but Otis Elevators has conducted an inspection and parts are currently being ordered to repair elevator. (Continued on LIC 809-C) 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 LIC 809) LPA inspected the facility food supply with the Director of Culinary Services and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Dietary modifications are in a binder in the kitchen. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed five of five staff training and fingerprint records and five of five resident records . LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 10, 2025. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Administrator and Libbie Retts, RN, MSN, Director of Health Services and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Incident Report received in our office on September 18, 2024. LPA was greeted and granted entry by the Concierge at 11AM. LPA met with Ashiman Gill, Administrator (AD) and LIbbie Retts, RN, MSN, CENP, Director of Health Services (DHS). The purpose of the visit is follow-up on an elopement by Resident #1 on September 16, 2024. LPA requested copies of the resident care plan, identification page and medical assessment since records are kept electronically. LPA also requested the staffing schedule for September 16, 2024. LPA noted there were three caregivers on the evening shift (2-10:30PM), one MedTech (10AM-6:30PM) and two charge nurses who overlap (7:30AM-4:00PM) and (2:30-11:00PM) based on facility staffing plan. A recent Care Conference was held on September 12, 2024 prior to the elopement. It is noted in the care plan that the resident is exit seeking but also engages in activities. At 4:45PM resident was not accounted for in the dining room and the elopement procedures were immediately implemented. Staff discovered resident within twenty-five minutes and redirected resident back to the community with no incident. Resident was assessed with no injuries and lab work was initiated to rule out other underlying causes. LPA interviewed resident prior to lunch and was engaged in a crossword puzzle with a 1:1 staff member. Family agreed with AD and DHS recommendations to have more staff rounds in the thirty minutes prior to dinner time. Staff were in-serviced regarding security and safety measures and expectations for the health and safety of the residents in the community. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident reported to our agency on July 29, 2024. LPA was greeted and granted entry into the facility by Ashiman Gill, Administrator (AD) at 10:30am and explained the reason for the visit. The purpose of today's visit is to follow-up on a self reported incident report received by our Duty Line on July 29, 2024 by Libbie Retts, RN, MSN, CENP, Director of Health Services (DHS). A medication error was reported that Resident #1 (R1) did not receive some medications for three days and medications were discovered by a staff member; who reported to the DHS. DHS immediately contacted physician and responsible party and investigated the incident with staff. Resident was monitored and did not have any effects from not taking the missing medications. Staff in-service training was conducted to prevent a medication incident from happening again. Corrective action was taken. Two of the four involved with the incident are no longer employed by Silverado. LPA requested Medication Administration Record (eMAR) for July 2024, in-service training and July staff roster relating to this incident. LPA interviewed AD Gill and DHS Retts. LPA visited R1 and observed resident engaging in activities. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.