Silverado Senior Living-beverly Place.

On May 8, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Assistant Director of Health Services Maria D Roldan and Regional Director of Operations Taylor Guinto. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (256) non-ambulatory elderly adults of which (92) may be bedridden ages 60 and above. Currently, the facility has (109) residents and (16) in hospice care. The facility is approved for (36) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (114) residents' rooms, (114) bathrooms (12) guest restrooms, a lobby, a theater, a gym, a library, a beauty salon, a dining area, a kitchen, a spa, a bistro, (3) wellness rooms, a game room, outside courtyards, and a parking garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The residents’ rooms were inspected 109 , 114, 145, 206, 230, 247, 307, 310, 334, 264, 342, and the gym. Bathrooms were operational with water temperature measured at 105.9 – 112.0 degrees F. A comfortable temperature was maintained in the facility at 73 - 76 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues 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 Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has conducted Fire and Disaster Drill March 13, 2026. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including activities and food menu calendars. LPA conducted an audit of resident #1-#7 (R1-R7) service files, and staff #1-#7 (S1-S7) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Stephanie Brynojolfson #6011996740 valid through July 7, 2026. The facility has a current liability insurance policy #SCP-143177739-02 from July 01, 2025 through July 1, 2026. No deficiencies were found during this inspection. An exit interview conducted with Taylor Guinto, and a copy of the report is provided.

On 12/12/24, the department conducted an interview with staff #1 (S1). On 12/13/24, the department conducted interviews with W1, and staff #1-#4 (S1-S4), and attempted to interview residents #2-#3 (R2-R3). On 01/21/2025, the department obtained medical records from Cedar Sinai Medical Center, and on 02/26/25, the department obtained medical records from Victory Hospice for R1. Furthermore, on 02/26/25, the department conducted an interview with staff #5 (S5). On 10/09/25, the department received the following documents: staff roster, resident roster, and Shower Logs for the months of November-December 2024. The department conducted interviews with S3-S4, and residents #4-#12 (R4-R12). Lastly, the department conducted a tour of the facility. The investigation revealed the following: Allegation: Resident sustained falls resulting in multiple injuries due to staff neglect. It is being alleged that a resident sustained two un-witnessed falls while in care, resulting in a fractured wrist, three fractured ribs, and a laceration on forehead due to neglect. The department conducted a review of records. Per Identification and Emergency Information form resident 1 (R1) was admitted to the facility on 08/12/2022 and was initially assessed as ambulatory with the use of a walker. Medical Records from Victory Hospice show that hospice services were initiated for R1 on 10/29/2024. Victory Hospice conducted an assessment of R1, and notes from that assessment state that R1’s health was declining, and that R1 was no longer ambulatory and considered a fall risk. On 11/12/2024, R1 was seen by Registered Nurse #1 (RN1) of Victory Hospice. RN1 stated that a head-to-toe assessment was completed of R1, and that there were no signs of pain. Facility Progress Notes for R1 revealed that on 11/17/24, R1 had an un-witnessed fall and was found on the floor of their room. It was noted that R1 denied hitting their head. An assessment was conducted by facility staff and there were no visible marks noted. R1 was able to move all extremities but complained of back pain and was given Tylenol for pain. The department reviewed visit notes from Victory Hospice. Per the notes R1 was seen by hospice Licensed Vocational Nurse #1 (LVN1) on 11/18/2024 for a follow up after a fall which occurred on 11/17/2024. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health. 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 Per visit notes from Victory Hospice, on 11/25/2024, R1 was seen by Hospice LVN1. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health. Per visit notes from Victory Hospice, on 11/26/2024, R1 was seen by RN1, and a head-to-toe assessment was completed of R1. It was noted that R1 displayed signs of depression and forgetfulness, and that there were no signs of pain. The department reviewed Facility Progress Notes which show that on 11/26/2024 R1 was observed with swelling of left wrist. Facility staff contacted Victory Hospice. Further review of visit notes from Victory Hospice dated 11/29/2024, state that R1 was seen by Licensed Vocational Nurse #2 (LVN2) who stated that a physical assessment showed R1 had pain in their left wrist and lower abdomen below the rib cage. R1 flinched when those areas were touched and left wrist displayed redness and swelling. The department reviewed Facility Progress Notes which noted that on 12/01/24 R1 had an un-witnessed fall and was found on the floor of their room. R1 was found lying on the left side of the bed with their head against the corner nightstand. R1 sustained an abrasion on the top left of their forehead, a bruise on their forehead, a red spot under their left eye, a bruise on their left shoulder and a bruise to their left hip. Victory Hospice and responsible party were notified, and R1 was taken via ambulance at 12:30 PM. An Unusual Incident/Injury Report was submitted to the department on 12/05/2024, depicting the same incident and adding that R1 was found around 08:45 AM and was transferred to Cedar Sinai Emergency room for further evaluation after a discussion with residents family. The department reviewed medical records from Cedar Sinai Medical Center, which showed that R1 was admitted on 12/01/2024 and was diagnosed with fractures of the posterior medial left ninth through twelfth ribs with a small left pleural effusion, a nondisplaced fracture of the left wrist, and a four cm left forehead laceration. 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 conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff could not corroborate the allegation. 4 out of 5 staff stated that R1 was moved to the second floor for a higher level of care and supervision. 3 out of 5 staff stated that after the second fall, R1 was provided with a bed that was six inches from the ground with high-low capabilities. An interview with S2 revealed that R1 had their first fall on 11/17/2024 and was found on the floor near their bed. S5 conducted a full body assessment and determined that R1 was able to move all their extremities without concern. After R1’s first fall, facility moved them to the second floor for a higher level of care as second floor of the facility has fall mats, two person assists, and more rotations completed by staff on the residents. S2 stated that R1’s second fall occurred on 12/01/2024 and that S4 found R1 on the floor lying on their left side with their head against the corner of their nightstand. S4 reported to S2 that R1 sustained an abrasion to their top left forehead, and there was a red spot under their left eye. R1 also sustained a contusion on their left shoulder and left hip. Once notified, S2 called Victory Hospice at 0845 hours and left a voicemail. S2 called Victory Hospice again at 0907 hours and reported the incident to Ana at Victory Hospice. S2 then called R1’s Power of Attorney (POA) to inform them of the incident, then called 911 and R1 was transported via ambulance to Cedar Sinai Hospital. The department attempted to interview R2-R3 but was unable to due to cognitive impairment. The department was unable to interview R1, as the resident passed away. An interview conducted with W1 revealed that R1 was at the facility from 08/15/2022 until 12/09/2024. W1 stated that R1 had their first fall on 11/17/2024, and that the facility informed them that that R1 was okay. After the first fall, R1 was moved to the second floor of the facility on 11/25/202 because R1 required a higher level of care. W1 stated that R1 sustained their second fall on 12/01/2024 and during fall R1 hit their head on the nightstand and sustained an abrasion to their forehead. R1 was taken to Cedar Sinai Hospital where they received stitches on their head, and were diagnosed with a left fractured wrist, and three fractured ribs. W1 stated that R1’s bed was changed to a high low bed as it was lower to the ground and that the facility held a conference with them to discuss options for improving R1’s care. Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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. 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 Allegation: Staff did not meet resident's hygiene needs. It is being alleged that a resident was observed with blood in their hair and had not been bathed. On 10/09/25, the department conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4staff said residents receive two showers a week and as needed. An interview with S1 revealed that R1 was showered twice a week, and as needed. S2 stated that Victory Hospice staff was assisting R1 with showers during the months of November 2024-December 2024. On 10/09/25, the department conducted interviews with R4 – R12. Of those interviewed, 4 out of out of 9 residents said that staff are meeting their hygiene and grooming needs, 2 out of 9 residents said they did not know if staff are meeting their hygiene and grooming needs, and 3 out of 9 residents did not answer. 4 out of 9 residents said that staff does assist them with bathing, 3 out of 9 residents said they did not know if staff assists them with bathing, and 2 out of 9 residents did not answer. 6 out of 9 residents said staff has not denied them services, and 3 out of 9 residents did not answer. A review of R1’s Physician’s Report documented under “Capacity for Self-Care” that the resident requires assistance with bathing. A review of the facility’s Shower Logs for the dates of November-December 2024 documented that residents were scheduled for at least two showers a week. The Shower Log for November 2024 documented that R1 received showers from staff at Victory Hospice. There were no showers for the month of December 2024 documented in the Shower Log. On 10/09/25, the department conducted a tour of the facility and observed residents to be clean and free from any odors. Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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 . An exit interview was conducted with Stephanie Brynjolfson, and a copy of the report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff behavior poses as a risk to a resident while in care. Allegation #2: Staff forced a resident to take medication while in care. The complaint alleges that the facility staff is unkind and forces Resident #1 (R1) to take medication without informing (R1). As a result of these issues, (R1) feels uncomfortable at the facility. No additional information was provided regarding these allegations. A review of Resident #1 (R1)’s identification and Emergency Information, (dated 02/27/25), indicates that (R1) was admitted to Silverado Senior Living Beverly Place (SSLBP) on that date. Previously, (R1) resided at Belmont Village Westwood from August 2024 to September 2024 and lived independently in a senior living community from November 2024 until February 2025. During (R1)’s time at (SSLBP), several medical visits occurred on March 23, 29, April 1, and April 4, 2025. Three of these four visits were related to the treatment of mental health condition. On April 9, 2025, between 1:15 PM and 2:45 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the (10) were unable to validate these allegations. (R1) asserted that the conduct of the staff did not present any risk and emphasized that no staff member ever coerced (R1) into taking medications against (R1)'s will. (R1) noted that the staff are kind and attentive, explains the medications, ensure understanding, and encourages questions. (R1) expressed that the feelings of despair stem from the challenges of adapting to assisted living, which significantly diminishes (R1)'s sense of independence and has nothing to do with staff’s behavior. (R2-R10) expressed appreciation for the staff and reported no issues with medication administration. On April 9, 2025, between 9:45 AM and 3:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members were not able to corroborate these allegations. Staff members (S1-S6) reported no issues with the behavior of staff or the way medications are given to (R1). (S4-S6) noted that (R1) asks questions about the medications but has never been forced to take or refuse them. (S1-S3) mentioned that (R1) is adjusting from independent to assisted living environment. It was also noted that (R1) was admitted to Cedar Sinai on April 4, 2025, due to experiencing emotional distress. (S1-S6) confirmed that all staff have received Workplace Sensitivity and Medication Administration training to handle these situations appropriately. (Evaluation Report continues LIC 9099-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 On April 9, 2025, between 11:45 AM and 12:35 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witness members were not able to verify these allegations. (W1) the Executive Director at Belmont Village Westwood, characterized (R1) as both cooperative and inquisitive regarding medication administration. (W2) a power of attorney for (R1), indicated that (R1) is presently assessing the suitability of assisted living concerning (R1)'s lifestyle needs that may have some reasons for (R1) emotional distress. The Department reviewed Resident #1 (R1) 's Physicians Report LIC 602A (dated 02/21/25) and Resident Appraisal (dated 02/17/25) revealed that (R1) is diagnosed with a mental disorder. Further review of (R1) Physician Order Medication Review (dated 03/23/25 and 04/01/25) and PRN Authorization Letter (dated 02/27/25) identified (R1) cannot determine own need for prescription or nonprescription medications and requires assistance with administration of drugs. (R1) is prescribed eighteen (18) prescription combined prescription and nonprescription medicines and is being treated for (R1) 's mental condition. Twelve (12) of the eighteen (18) medications have adverse side effects or negatively affect (R1) 's mental status (ref: National Institutes of Health - NIH). An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including ADLs and Behaviors, Psychosocial Needs, Challenging Behaviors, Basic Essentials, Person Center Care and Medication Management. During the visit on April 4 and 14, 2025, the Department identified that the facility promotes the rights of its residents. To improve the environment, posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated . An exit interview was conducted with Stephanie Brynjolfson, and copies of the reports were provided.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced case management visit regarding the relocation of (45) residents of Silverado Senior Living—Calabasas #197609117 to the facility listed above due to mandatory evacuation orders from Fire Advisory. LPA met with Executive Directors from both facilities, Patrice O'Grady and Stephanie Brynjolfson, and explained the purpose of the visit. LPA conducted a health and safety check during the visit, and no concerns were observed. LPA reviewed and obtained resident and staff rosters for both facilities. Per an interview with Executive Director Patrice O'Grady, (45) residents have been relocated to Silverado Senior-Beverly Place. The facility has sufficient beds, hygiene supplies, bedding, and linens, and everyone has a designated private or shared room with bathrooms in each room. The dining room is large enough to accommodate all residents on the first and second floors. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications, MARs, and resident's files of Silverado Senior Living-Calabasas are available electronically. The medicines have been transferred to Silverado Senior-Beverly Place and stored in locked cabinets. (LPA) inspected emergency food and water supplies. LPA observed that the facility has sufficient 30-day Personal Protective Equipment and incontinent supplies. Brynjolfson confirmed that the facility has backup generators. There are (22) ambulatory and (23) non-ambulatory residents transferred from Silverado Senior- Calabasas. There are (32) who use assistive devices, and (43) who require assistance with incontinence care. LPA inspected rooms #242, #246, #317, and #331 and found to be in compliance with Title 22 regulations. The Licensee stated that both facilities use the same vendors, pharmacy, and home health agencies, which allows them to provide the same level of continued care for the residents. (Evaluation Report continues 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 There is sufficient staffing available to provide care for residents of both facilities. It has been verified that routine Fire Inspection and Disaster Drills were last tested on 12/15/24. O'Grady confirmed that all families and responsible parties of Silverado Senior-Calabasas residents have been notified about the relocation either via calls or emails. O'Grady confirmed that residents from Siliverado Senior-Calabasas were health screened prior to the relocation. An exit interview was conducted, and Executive Directors Brynjolfson and O'Grady were provided with a copy of this report.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff handles residents in a rough manner. The details of the complaint alleged that staff handled (R1) in a rough manner. It is reported that staff #3-#4 were involved in an incident with (R1) on 12/17/23, where (R1) fell and sustained a left arm injury. Further details provided the incident took place during (R1’s) vital checks was taking place and that (R1) became unsettled and aggressive and that (S4) pushed (R1) down causing a fall and sustained injury. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) who claimed this accusation was false. (S1) stated that an investigation on this matter concluded and no findings of abuse were found. (S1) described on an Incident Report LIC 624 (dated: 12/22/24), that (R1) was restless and aggressive with (S4), and a body movement with (R1) caused (R1) to lose balance and fall back. (S1) indicated (S3 and S4) interviews resulted in no negative feedback on care concerns or work performance about (S3). (S3) claimed to have not been observed how (R1) fell. (S3) claimed that staff #4-#5 (S4-S5) were both assisting (R1) on 12/17/24 when the fall incident took place. (S5) reported the incident to (S3) in which (S5) provided inconsistent times when the incident occurred. (S3) claimed that there were tensions between (S4 and S5) and did not get along and may have given inaccurate reporting of what occurred. (S3) assessed (R1) and noted a skin tear on the lower left arm due to the range of motion and found no head injury. (S3) stated first aid treatment was administered for the skin tear. (S4 and S5) were not available for an interview or comments on this matter. On 12/26/23, between 10:00 am – 01:00 the Department interviewed (7) out of (10) residents could not corroborate this allegation. Seven (7) out of ten(10) residents stated the facility staff provided acceptable services, complimentary, and had not experienced any mistreatment. (R9-R10) refused to be part in an interview. As a result of the Department reviewing (R1’s) Service Plan (09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23), Incident Report LIC 624 (dated: 12/22/24), revealed that (R1’s) mental condition is associated with behavior disturbance, anxiety, depression, sundowning, and a fall risk. Based on the gathered information, there is not enough evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-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 Allegation #2: Staff did not ensure that a resident’s incontinence needs were met. Allegation #4: Staff do not monitor residents for change in condition. The details of this complaint alleged that staff do not ensure resident #1 (R1) incontinence needs are met. Information provided claimed that (R1) is not being checked every two hours or checked throughout night hours for diaper changes. This coincides with a report that staff do not monitor residents' changes in condition due to incontinent services. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) staff #1-#3 who claimed this accusation was false. (S3) claimed to have experienced that when resident refuses service the staff will send a new face, and they will accept our assistance. (S3) stated that (R1) is often upset and refuses the staff to assist with (R1’s) toileting needs. The staff would often send new faces that (R1) is familiar with and will allow for assistance. According to (S3), the residents are not in the right frame of mind and do not want to be groomed or not feeling well. As soon as they tell me they feel dizzy, I will take their vital signs to ensure everything is okay. Residents' hydration is monitored and assisted by caregivers. I look at their color, their lips, and their skin. If they appear to be dry, they need more liquids. For instance, if residents show elevated blood pressure, that's the first sign of dehydration. (S4 and S5) were unavailable for an interview or comments on this matter. On 12/26/23, between 10:00 am – 01: 00 pm, the Department interviewed (7) out of (10) residents could not corroborate this allegation. Seven out of ten (10) stated the facility staff provided adequate incontinent services or had no issues. Seven (7) out of ten (10) claimed the staff do monitor their change in condition and had no concerns on this matter. (R9-R10) refused to take part in an interview. As a result of the Department reviewing (R1’s) Service Plan (dated: 09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23), Incident Report LIC 624 (dated: 12/22/23), Facility NOC Resident Assignment/Resident Care Schedule (dated: 12/01/23-12/19/23), and Caregiver Daily Rounds Schedule (dated: 12/01/23-12/19/23), revealed that (R1’s) required assistance with toileting. However, (R1) did not require continuous bed care, had no history of skin condition or breakdown, and monitoring, repositioning, and diaper changes were performed on (R1). Based on the gathered information, there is insufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-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 Allegation #3: Staff do not ensure that resident’s dietary needs are met. A resident's diet was allegedly not provided according to the details of this complaint. It is reported residents are not provided with water or snacks. They were no further detailed information on this matter. On 12/26/23, between 10:00 am – 01:00 pm, the Department interviewed (7) out of (10) residents could not support this allegation. Seven (7) out of ten (10) were complimentary of the food and claimed it was pleasing, and ample refreshments and snacks were offered throughout the day. Two (2) out of ten (10) residents claimed to be on a special diet and that their dietary needs were fulfilled. (R9-R10) did not want to take part in an interview. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) staff who claimed this allegation is untrue. (S3) stated most of the residents are on a mechanical so diet, while some are on puree. The kitchen creates individual special orders for those on special diets as well according to their care plan. (S3) reported that plentiful water and snacks are provided during mealtimes. As a result of the Department reviewing (R1’s) Service Plan (dated: 09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23) and Resident’s Dietary Report (dated: 12/26/23), revealed that (R1) was not on any special diet and no medical history of due to dehydration or malnourishment. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #5: Staff did not provide resident with clean linen. The detail of this complaint alleged that staff do not provide residents with clean linen. It is reported due to the abundant of incontinent activities, the residents are not provided with clean linens. There were no further details on this matter provided. On 12/26/23, between 01:30 pm – 04: 00 pm the Department (2) ou of (3) staff who claimed this accusation was fabricated. (S3) claimed the caregivers have a schedule of linens. We don't wash that with their personal clothing as sometimes people do have accidents. There are ample linens provided to our residents in care. Linens are provided daily or as needed to residents according to (S3). On 12/26/23, between 10:00 am – 01: 00 pm, the Department interviewed (7) out of (10) residents. could not attest this allegation. Seven (7) out of ten (10) stated that linens are changed regularly or had no concerns on this matter. (R9-R10) refused to take part in an interview. (Evaluation Report continues LIC 9099-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 As a result of the department observation during the investigation on 12/26/23, the Department observed storage closets filled linens, and the linens observed appeared to be clean and presentable. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #6: Staff did not report incident to appropriate parties. The details for this complaint alleged the incident with resident #1 (R1) on 12/17/24 was not reported to the appropriate parties. The reports claimed the (R1’s) family was provided false information on (R1’s) fall incident and gave inaccurate information on how (R1) sustained the arm injury. On 12/26/23, between 01:30 pm – 04: 00 pm the Department interviewed (2) out of (3) staff claimed this accusation was false. (S3) stated in general when an incident occurs, after we handle the situation, the nurse on call, will dispatch for assistance to call 911. Paramedics arrive and I provide them with paperwork. I inform the responsible parties by telephone. I provide written information to (S1) and it is cross reported to authorized parties. (S1) claimed the incident was reported in an Incident Report LIC 624 (dated: 12/22/24) to authorized representatives appropriately. On 12/26/23, between 10:00 am – 01: 00 pm the Department interviewed (7) out of (10) residents could not validate this allegation. Seven (7) out of ten (10) stated the facility followed proper protocol and reports to authorized representatives. (R9-R10) refused to take part in an interview. As a result of the Department reviewing (R1’s) Incident Report LIC 624 (dated: 12/22/24 and the facility’s email correspondences (dated: 12/18/24) revealed incident involving (R1) was discussed, investigated, and reported to (R1’s) authorized representatives. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Between 12/26/24

Licensing Program Analyst (LPA) Sparkle Day conducted a Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Incident Report which occurred on 09/06/2024. LPA met with Staff #1 Administrator Stephanie Brynjolfson who assisted with the visit. On 9/6/24 at 8:15am resident #1 (R#1) received incorrect dosage of Ativan from Silverado Hospice RN, W#1 Jane Edwards. R#1 was expected to take a dosage of .025 of Ativan and was administered a dosage of 2.5 mg of Ativan. Immediately after administering incorrect dosage of Ativan to R#1, the Hospice Nurse informed the Nurse at the Nurse station Staff #2 Maria Gabriel who informed the Asst Director of Health Services , The Health Services Director, the Physician and the family. During todays visit LPA interviewed Administrator Stephanie Brynjolfson Staff #1, Director of Health Services Staff #3, Tommy Anderson and Asst Director of Health Services Staff #4 , Maria Roldan], Facility staff then followed Physician instructions Assessed and monitored R#1. LPA reviewed the following current staff training : Identifying and Managing Medication Errors and Adverse Consequences dated 9/20/24 ,Administering Medications to Hospice Residents instead of Hospice nurses dated 9/9/2024 and Resident Medication distribution dated 9/20/24 LPA observed a new policy of the facility regarding Medication distribution with Hospice nurses indicating whenever a resident is on hospice and needs medication the hospice nurse will communicate the information to the Silverado Beverly Place charge nurse. At that time the charge nurse will verify all orders and administer the medication to the residents. LPA Day obtained a Memo from R#1 physician that indicated that Ativan can be used at the dosages of 2 to 6 mg daily with the maximum of 10 mg daily and does not feel that the 2.5 mg dosage would led to the demise of R#1. LPA did not observe deficiencies therefore no citations were issued at this time. LPA requested the death certificate from the facility. An exit interview was conducted, a copy of the Report were provided to Administrator Stephanie Brynjolfson .

Regarding Allegation #2, FACILITY IS UNDERSTAFFED It was alleged that there is a staffing problem on the 3rd floor of the facility. On 7/2/2024 at approximately 11:06 LPA interviewed Resident #1- R#7. 7 out of 7 residents deny the allegation. Residents state there is always enough staff on the 3rd floor to meet their needs. LPA interviewed Staff #1 - S#5. 5 out 5 staff deny the allegation. Staff state the 3rd floor is the LOFT where the residents are pretty independent and don't require alot of care, however staff are always there to assist and supervise residents. LPA toured the 3rd floor (The Loft) and found the residents are independent and don't require much assistance. LPA observed that there is a 1 -7 staff to resident ratio on the 1st floor, A 1-6 staff to resident ratio on the 2nd floor and 1 - 6 staff to resident ratio on the 3rd floor. All floors have a 5 staff standby resident assistance if needed. Based upon this investigation , LPA finds that 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]. Regarding Allegation #3- Incomplete Admission documents It was alleged that the facility is not giving residents or residents' families all necessary documents during admission. 0n 7/2/2024 at around 11:50 am LPA interviewed Staff #1 - S#5 regarding the allegation. 5 out of 5 staff deny the allegations. Staff state that all residents and/or residents families are given a copy of their admission documents at time of admission with their signatures. Staff informed LPA that residents have a choice of receiving a paper packet of their signed admission documents or they can get their documents Docu Sign, in which the documents are emailed to them with their signatures. LPA interviewed Resident #1 - R#7 regarding this allegation. 5 out of 7 residents deny the allegation and state they were given copies of everything signed at admission. The other 2 residents do not recall. Based upon this investigation , LPA finds that 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 conducted with A copy of this report was left with

Licensing Program Analysts (LPAs)/Retired Annuitants (RAs) Sparkle Day and Elizabeth Ceniceros conducted an unannounced Annual Random site visit using the CARE Inspection Tool. LPAs/RAs conducted a risk assessment with Staff #2 (S2: Jasmine Garcia). Staff #2 informed LPAs/RAs that the facility has no COVID cases nor do the residents or staff have symptoms. LPAs/RAs met with the Director of Operations/Administrator (A1: Taylor Giunto), Staff #1 (A2: Stephanie Brynjolfson, Family Ambassador), and Staff #3 (S3: Maria Diaz-Anna, Assistant Director of Health Services). LPAs/RAs explained the purpose for today’s visit. The facility is licensed to operate for (256) non-ambulatory elderly adults of which (92) may be bedridden - ages 60 and above. Currently, the facility has (112) residents and (14) in hospice care. The facility is approved for (36) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (114) residents' rooms, (114) bathrooms (12) guest restrooms, a lobby, a theater, a gym, a library, a beauty salon, a dining area, a kitchen, a spa, a bistro, (2) wellness rooms, a game room, outside courtyards, two (2) elevators (north and south) and underground parking. LPAs/RAs Day and Ceniceros toured the facility and observed residents in care. There were no bodies of water on the premises. The following residents’ rooms were inspected: #133, #145, #146, #217, #219, #220, #242, #248, #318, #325, #324. Bathrooms were operational with water temperature measuring at 107*F – 112*F degrees. LPAs/RAs observed beds and bedding supplies to be in good condition, adequate lighting, and sufficient storage for residents’ personal belongings. Bed linens, comforters, and bath towels are fully stocked and stored in cabinets. There is a comfortable room temperature maintained in the facility within 74.0*F – 76.0*F degrees. LPAs/RAs Day and Ceniceros observed the facility to be furnished at the time of this visit. Storage areas for 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 personal hygiene, cleaning supplies, toxins, and sharp objects were stored and inaccessible to residents in care. The commercial-size kitchen was inspected and there is a sufficient food supply of perishables and non-perishables. Facility’s smoke detectors and carbon monoxide systems are inter-connected (w/back-up battery) can be observed in the hallways and rooms. LPAs/RAs observed a pull-switch, fire alarm sounding device observed in the hallway/main entrance. Fire extinguishers are fully charged with posted signs. First-aid kits are fully stocked (w/first-aid manual). The last fire drill was conducted on 02/23/24. LPAs/RAs Day and Ceniceros reviewed Residents #1 - #11 Medication Records Administration (MAR) and observed the MAR to be maintained in an electronic health records system. LPAs/RAs observed the facility's infection control practices and also the screening protocols for visitors, staff, and residents. LPAs/RAs observed: sanitizing stations in common areas and restrooms; multiple first-aid kits maintained in order and complete with required items; a 30-day supply of Personal Protective Equipment (PPE); and all mandated inspection control posters posted at the main entrance. LPAs/RAs Day and Ceniceros conducted an audit of Residents (R1 - R11) records and Staff (S1 - S11) personnel files/training records that are in complete order. LPAs/RAs conducted random interviews of five (5) residents and five (5) staff members. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs/RAs did not observe deficiencies, therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the Regional Director of Operations/Administrator (A1: Taylor Giunto) and Family Ambassador/Administrator (A2: Stephanie Brynjolfson).

This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023. The investigation revealed the following: Allegation: Staff did not intervene in resident-on-resident altercations. It is alleged that a resident was walking to lunch and another resident hit them in the head. LPA interviewed staff S1– S10, and 10 out of 10 stated that no resident had reported that they were physically attacked by another resident. LPA interviewed residents R1 – R10, and 9 out of 10 stated that they had never been attacked by another resident. Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." 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. Allegation: Staff did not ensure that resident received medical attention while in care It is alleged that a resident was shoved by another resident and their shoulder was injured to the point of needing an injection for pain. LPA interviewed staff S1 – S10, and 9 out of 10 of those interviewed stated that no residents reported that they were physically attacked by other residents. S1 added that at least one resident reported to them that they were attacked by a homeless male while out walking with a friend. LPA interviewed R1 – R10, and 9 out of 10 residents denied that anyone has hit or attacked them there. R1 stated that they told S5 and S1 that they were physically attacked. S1 called the police regarding the incident but no official report was taken and no injury was noted per S1. S1 also added that no LIC 624 form was completed and submitted to Licensing at the time. During LPA's interview with S10, LPA interviewed S10 who stated that R1 complained of chest and shoulder pain. R1 was evaluated by facility nurse and R1 was referred to Valley Internal Medicine where the resident was evaluated. LPA interviewed W1 regarding alleged altercation and both R1 and W1 stories coincided with each others account of what happened. Cont'd on 9099-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 This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023. Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." 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. An exit interview was conducted with Administrator Assistant, Stephanie Brynjolfson and a copy of the report was provided.