Silverado Senior Living- Newport Mesa.

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

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

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

Records reveal that on average facility has seven to eight Caregivers in the AM shift, five to six Caregivers in PM shift and three during NOC shift. Records also reveal that facility has on average staffing ratio of 9:1 during AM shift, 11:1 during PM shift and 17:1 during NOC shift. LPA made the following observations during investigation; Facility is a Residential Care Facility for the Elderly that specializes in Memory care. Facility has capacity of 82. During investigation visit on 3/11/24 facility had a census of 51 and on todays date census of 48. During visit on 3/11/24, LPA observed 13 care staff assisting residents in facility. LPA observed that facility is divided into three neighborhoods for residents: Newport, Country Kitchen and Lido. During investigation it was revealed to LPA that staff are assigned to each neighborhood. During visits LPA observed residents relaxing in bedrooms watching TV, relaxing in common area dining rooms eating meals, and being assisted by staff in hallways & outside patio areas. Interviews with staff and residents were conducted and revealed the following, seven of seven staff interviewed stated that facility has three shifts per Caregivers and that caregivers are assigned to one of three neighborhoods inside facility. Interviews with staff revealed that five of five Caregivers stated they assist residents with Activities of Daily Living (ADL’s) such as showering, toileting, making bed’s, dressing, feeding, and transporting. All staff interviewed confirmed that no residents or family members have expressed recent concerns about the quality of care provided to residents. Interviews with Residents revealed that five of five residents stated that they had no complaints about staff members that they like the staff, staff are available when they need, and two of five residents stated that the facility is meeting their care needs. Interview with family witness confirmed that they had no issues with staffing and felt that the level of care was meeting residents needs. Based on observations made by LPA, interviews conducted, and records reviewed although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff are not providing adequate care to dementia residents is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Heather Younan and a copy of this report was reviewed and provided at the time of this visit.

Routine Wellness Result for 6/30/2023 indicated R1 was fully independent of peri care. The Routine Wellness Results from 7/31/2023 to 9/29/23 notated resident’s assessment for peri care indicated R1 had changes to bladder incontinence and is no longer independently managed. Interviews also revealed that R1 can go to bathroom on their own however staff help assist resident with incontinence care by cleaning and changing resident after resident has had bowel movements. Interviews revealed that R1 needs assistance with wiping after using restroom. On 8/29/2023 facility sent out notification letter, notifying responsible party of R1’s change in peri care requiring incontinence care and beginning 9/1/2023 facility was implementing a charge for monthly incontinence care. Resident Billing Invoice statements indicated no incontinence charges were applied to bills for the months of June to September of 2023. Resident’s Billing Invoice dated 10/1/2023 shows an incontinence care charge was billed for the period of 9/1/23 to 9/30/23 as well as statement for care provided 10/1/23 to 10/31/23. Interviews revealed that residents account is enrolled to autopay. Invoice statements confirm resident’s account is currently paid up to date with no balances pending. Interviews revealed that at the request of responsible party, facility is in process of reimbursing resident’s account due to improper notification in person. Based on interviews conducted and documents revealed, allegation facility charging for un-needed services is deemed Unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.