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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005652
Report Date: 07/22/2025
Date Signed: 07/22/2025 05:09:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250715100345
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:ASHIMAN GILLFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 48DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Ashiman Gill, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mismanaged residents' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation into a complaint received in our Regional Office. LPA met with Ashiman Gill, Administrator (AD) and explained the purpose of the visit.

The purpose of the visit is to investigate an incident on Sunday, July 13, 2025 that staf mismanaged residents' medication.

LPA requested the following documents: Staff roster with phone numbers, Current staff schedule, and facility Medication Policy. LPA requested copies of Resident #1 (R1) and Resident #2 (R2)'s: Identification and Emergency Information, Care Plans, Physicians Reports and Medication Administration Records (MARs). LPA also requested to review Staff #1 (S1)'s file and in-service documentation regarding medication administration practices.
(Continued on LIC 9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20250715100345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/22/2025
NARRATIVE
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(Continued from LIC 9099)

On July 13, 2025 at 5:40pm a nurse from an outside agency was dispensing medication and was preparing the meds on the Med Cart. Staff #1 (S1) offered to assist the nurse and grabbed the prepared meds for Resident #1 (R1) and gave them to Resident #2 (R2). S1 immediately realized the mistake and staff informed AD Gill, the Vice President of Clinical Services, who is a Nurse Practitioner, and the community's Medical Director. The Responsible Party (RP) was also contacted. S1 is not trained to dispense medications and is not a nurse; nor a Medication Technician (Med Tech). The allegation that staff mismanaged residents' medication is Substantiated.

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. Upon interviews with staff, R2 was closely monitored throughout the night and vitals were taken three times. S1 also remained by R2's bed until midnight. The Nurse Practitioner also visited resident the next morning and there were no adverse effects and resident remained stable, alert and at baseline. An Unusual Incident Report was also faxed to the Regional Office on July 14, 2025.

Based on LPA's record review, observations and interviews, the preponderance of evidence standard has been met, therefore the allegation that staff mismanaged residents' medication is Substantiated.
The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was given to the facility along with a copy of the Confidential Names LIC 811,LIC 9099-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250715100345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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Administrator (AD) conducted an all-staff in-service on July 14-15, 2025 regarding proper Medication Administration procedures and documentation. AD also had a written counseling with Staff #1 on July 16, 2025 regarding clinical role boundaries.
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(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on LPA record review and interviews, this requirement was not met for one of one residents which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3