374604254-3-7-2025-08-AS-RCLK-DG99JZ-20250430232533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604254
Report Date: 03/07/2025
Date Signed: 03/07/2025 05:12:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20250228165315

FACILITY NAME:	SILVERADO SENIOR LIVING-ENCINITAS		FACILITY NUMBER:	374604254
ADMINISTRATOR:	SABRINA PEGROSS		FACILITY TYPE:	740
ADDRESS:	335 SAXONY ROAD		TELEPHONE:	(949) 240-7200
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	122	CENSUS: 76	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Administrator Dyan Summerell and Kaitly Collins, Director of Resident and Family Services		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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- Facility did not allow resident to refuse medical care
- Facility did not meet resident’s nutritional needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Caroline Fitzgerald, Concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Dyan Summerell and Kaitly Collins, Director of Resident and Family Services.

The Department’s investigation consisted of interviews with staff and attempted interview with resident, records review of relevant documents pertinent to this investigation, and LPA observations. On February 28, 2025, it was alleged facility did not allow resident to refuse medical care, and facility did not meet resident’s nutritional needs.

(Continuation on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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 08-AS-20250228165315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS	FACILITY NUMBER: 374604254
	VISIT DATE: 03/07/2025

NARRATIVE

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(Continuation of LIC9099)

It was specifically alleged resident #1 (R1) had a catheter they did not want. Interview with the Executive Director, Diane Summerell, said they were following the R1s PCP orders upon admission. R1 ended up being discharged from the hospital with a catheter. They were aware R1 had ongoing issues with the use of the catheter but moved into the community with the catheter already in place. They did say that Home Health was coming out to assist R1 with their catheter. Per Executive Director, R1 currently does not have a catheter in place. Interview with staff #1 (S1) confirmed that the resident had the catheter in place when they had moved into the facility on or about December 10, 2024, but since has been removed. A review of records revealed that the hospital assessment, dated December 9, 2024, said a urinary retention Foley was placed. Hospital care plan, dated December 11, 2024, noted that resident had not made progress and recommended to address the barriers to include discharge with foley catheter. They did do a home health referral to CenterWell for PT and RN- foley care. Resident was admitted to the facility on or about December 10, 2024. According to R1’s preplacement appraisal, dated December 11, 2024, R1 had a new Foley at the hospital as they had failed their trial to remove it twice. Residents Physician’s report, dated December 3, 2024, showed the resident did have a Foley catheter. Home Health care notes show that they were assisting resident with their catheter about every 3 to 4 days since December 2024 through February 2023. Hospital discharge documentation, dated February 25, 2025, showed that R1 was sent to the hospital for displacement of Foley catheter. On March 7, 2025, LPA briefly spoke with R1, but was unable to qualify the residents interview. LPA observed that they did not have a catheter in place or bags on their person. Based on the aforementioned this allegation is deemed unsubstantiated.

It was specifically alleged that the facility did not wake resident to have their meals. Interview with Executive Director Summerell said that the resident did come in with malnourishment. According to S1 the facility does have a Country Kitchen where they provide residents with many snacks if they are feeling hungry after meals. They are aware their caregivers are provided a list of residents to care for and assist them to their meals. According to S2, R1 is one of their good eaters. If they are asleep, S1 said they would hold on to their dinner plate and give it to them when they awake to have their dinner. At times R1 may be hungry throughout the night but is able to get a snack from their Country Kitchen. According to S3, they have worked with R1. S3 describes R1s eating customs to be a very well eater. They corroborated S2s statement, that they save residents food when its dinner time and the resident is sleeping.

(Continuation on LIC9099-C)

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250228165315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS	FACILITY NUMBER: 374604254
	VISIT DATE: 03/07/2025

NARRATIVE

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(Continuation of LIC9099-C)

S3 said that it is not normal for R1 to be sleeping at dinner time but has occurred. R1 will also have all types of snacks if they are hungry. They go into their Country Kitchen and have a snack. A review of records revealed resident had a hospital visit prior to admission, dated November 21, 2024, and PCP serviced resident on November 22, 2024 that noted that resident’s appearance was an underweight elderly person. The hospital assessment noted that the resident had moderate to severe malnutrition. On November 30, 2024, the resident was seen at the hospital, and their assessment regarding the resident’s weight did not change – the resident was still underweight. An email dated December 10, 2024, from the facility did make staff aware R1 did have a malnourishment diagnosis with significant weight loss upon R1s admission. Hospital progress notes dated December 7, 2024, said the resident had an appetite that day and weighed 51.2 kilograms (approximately 112.87 pounds) for their last 10 readings. Facility weight notes show that the resident has been fluctuating in weight between 113 – 120 pounds the past month. The facility is obtaining Nutritional Care Notes from Dining which indicate R1s diagnosis, weight, plan and goal to address their condition. During LPA’s visit on March 7, 2025, they saw R1 was in the activities room with a peanut butter and jelly sandwich and a water and had another before LPA left.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

The report was discussed and an exit interview was conducted with Executive Director Dyan Summerell and Kaitlyn Collins, Director of Resident and Family Services. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Summerell at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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