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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 04/15/2025
Date Signed: 04/15/2025 05:16:59 PM

Document Has Been Signed on 04/15/2025 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR/
DIRECTOR:		ASHIMAN GILLFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 70CENSUS: 36DATE:
04/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Ashiman GillTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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LPA Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the incident involving Resident 1 (R1) that took place at the facility on December 20, 2024. LPA met with Administrator (AD) Ashiman Gill and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, staff roster, staff schedule, R1’s emergency contact information, R1’s physician’s report dated November 1, 2023, R1’s resident appraisal dated September 13, 2021, R1’s Physician order review (prescription list), facility surveillance camera footage from December 20, 2024, photographic evidence of R1 from December 21, 2024, Kaiser Permanente medical records dated December 20 to 24, 2024, R1’s after visit summary records dated December 26 and December 31, 2024.

The investigation revealed following, The Director of Resident Engagement (DRE) Alyssa Herris led an engagement activity for residents on December 20, 2024, around 3:00 pm. The activity consisted of making a dried resin floral coaster. R1 was one of five participants. Two staff members were present during the activity. There were two bottles of Epoxy Resin (glue) that were mixed and poured in a red solo cup for residents to use in making the coaster. The DRE reported that putting resin in a cup was typical whenever they had a similar activity. The DRE admitted to placing the cup of resin on the table next to R1 and turned away from R1 to redirect another resident. R1 picked up the cup and started to take a few sips. The DRE turned and was facing R1 but was talking to another resident. The DRE saw R1 holding the cup by their mouth, so they went to R1 and took the cup away from R1. This information was verified by surveillance camera footage. R1 then stated, “I don’t want any more of that.” The DRE immediately notified the facility’s Director of Health Services (DHS) Elizabeth Retts. The DRE and DHS gave R1 some water and contacted the Nurse (N1) to assess R1 at 3:27pm. N1 reported that R1’s vital signs were normal.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SILVERADO BREA LLC
FACILITY NUMBER: 306005652
VISIT DATE: 04/15/2025
NARRATIVE
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 Poison control was called at 3:31 pm. Poison control advised staff to call 911 if R1 fails to eat and drink or if they start vomiting. 10 to 15 minutes later R1 had difficulty talking, became dizzy and R1 started to vomit. Staff called 911 at 3:53 pm. At approximately 4:00 pm the paramedics arrived and R1 was transported to St. Jude Medical Center. R1 was transferred from St. Jude Medical Center to Kaiser Permanente Irvine at 5:18 pm. R1 was hospitalized at Kaiser Permanente from December 20, 2024, to December 24, 2024. R1 suffered chemical burns on their tongue and lips. R1 was diagnosed with Acute hypoxemic respiratory failure and Angioedema (swelling in throat) due to a toxic substance. R1 was prescribed a puree diet, speech therapy and home health visits after their discharge. R1 had follow up appointments on December 26, 2024, and December 31, 2024, to check on their recovery. The facility reported the incident to the Agency on December 21, 2024. R1 was interviewed but could not recall the incident or their hospitalization. R1 ingested a toxic substance that led to Acute hypoxemic respiratory failure and Angioedema (swelling in throat). R1’s physician report shows; R1 has Mild Cognitive Impairment, their mental condition consisted of confusion and disorientation. R1 was noted to being able to follow instructions and communicate their needs. R1’s appraisal and medical records noted R1 has Dementia. The DRE reported that the resin, that was poured in the cup was from 2 different bottles of resin that contained different types of resin. Each bottle of resin had a different warning. Bottle 1 labeled epoxy resin A and bottle 2 labeled epoxy resin B. Bottle 1’s warning states, “causes skin irritation, causes serious eye irritation, may cause an allergic skin reaction, do not get in eyes. Do not get on skin.” Bottle 2’s warning states, “harmful if swallowed, harmful if contact with skin, causes serious eye damage. Do not swallow. Do not get in eyes.” The DRE poured a small amount of resin from each bottle in the cup and then put the cup on a table next to R1. The resin in the cup is a poisonous substance and the cup was unattended as the DRE was attending to another resident when R1 drank from the cup. After the incident R1 was hospitalized. R1 was discharged from the hospital to another facility.

During the course of the investigation, the Department obtained sufficient evidence to substantiate, that during the incident the facility failed to ensure that poisonous substances which could pose a danger to residents are not left unattended if outside the locked storage. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 05:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 04/15/2025 at 04:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SILVERADO BREA LLC
FACILITY NUMBER: 306005652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2025
Section Cited
CCR
87309(a)

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Type A: 87309(a) – 87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Licensee agrees to not use resin in any activity involin any involving residents. Licensee agrees to keep all substances in the above regulation CCR 87309 locked and inaccessible to residents. Licensee agrees to train all staff regarding CCR 87309. Licensee to forward proof to LPA.
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This requirement was not met as evidenced by, based on documents, interviews and video surveillance footage, the licensee did not ensure that poisonous substances are not left unattended if outside the locked storage, as a result R1 suffered chemical burns, Acute hypoxemic respiratory failure and Angioedema (swelling of throat), which poses an immediate health and safety risk to persons in care. CIVIL PENALITY ASSESSED.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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