Inspection Reports for
Silverado Belmont Hills Memory Care Community

The visit was triggered by two incidents reported on 3/8/26 and 3/12/26 involving Resident 1 and Resident 2 found undressed and involved in intimate acts. The incidents were investigated and addressed with no new incidents observed since.

The visit found that two residents with Alzheimer's dementia were involved in incidents of intimacy, which were addressed by updating their service plans and relocating one resident. No citations were issued during the visit.

During the visit, the Licensing Program Analyst delivered amended copies of LIC9099 and LIC9099D issued on 2025-02-25. The report was reviewed with the administrator and a copy was provided.

The facility was toured including resident neighborhoods, administrative areas, and kitchen. Observations noted clean, odor-free environments, locked medications and chemicals, proper water temperatures, and up-to-date emergency drills. Resident and staff files were reviewed and found complete and compliant. No citations were issued during the visit.

The visit was complaint-related, following an incident of aggression between residents. The complaint was investigated and no citations were issued.

The investigation found that Resident 1 became agitated and aggressive towards staff, and Resident 2 intervened by hitting Resident 1 to protect the staff member. Both residents were assessed with no injuries noted. No citations were issued during the visit.

The visit was complaint-related due to an incident involving two residents with dementia who had a physical altercation. The incident was investigated, and corrective actions such as staff training and medication adjustment were implemented. No citations were issued.

The investigation found that two residents with dementia had a second altercation incident where one resident punched the other. Staff conducted verbal training to separate the residents, and one resident received a medication adjustment. No citations were issued during the visit.

The investigation confirmed the gate lock failure which allowed the resident to leave the facility. The locks were repaired the same day by a third-party vendor, all exit gates were checked and found locked during the visit, and the gates were re-keyed. No injuries or citations were noted.

The Licensing Program Analyst met with the Administrator and delivered an immediate exclusion letter for Staff #1. The report was reviewed and discussed with the Administrator, and a copy was provided.

The Licensing Program Analyst met with the Administrator and delivered an immediate exclusion letter for Staff #1. The report was reviewed and discussed with the Administrator, and a copy was provided.

The complaint investigation was unsubstantiated. Allegations included resident sustained pressure injuries and dehydration due to staff neglect. The resident had a history of pressure ulcers and dehydration. Facility staff monitored water intake despite not being a skilled nursing facility. Home health wound care was provided after hospital discharge. No conclusive evidence was found to substantiate the allegations.

The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, resulting in the allegations being unsubstantiated.

The Licensing Program Analyst met with the Director of Health Services and delivered an immediate exclusion letter for two staff members. The report was reviewed and discussed with the Director of Health Services.

The investigation found that the 1:1 caregiver was sitting outside the resident's door holding the door knob to prevent the resident from leaving. The caregiver was terminated, new medications were ordered, and a new caregiver was hired. No citations were issued during the visit.

The facility was found to be clean, odor-free, and well-maintained with no fire safety hazards or tripping hazards observed. Resident and staff records were complete and up to date, medications were properly stored and accounted for, and emergency drills were conducted quarterly.

The facility conducted an internal investigation and behavior mapping for Resident 1, confirmed all perimeter gates were locked and secure, and assigned one-on-one caregiver supervision. No citations were issued during the visit.

The visit was triggered by a reported incident where Resident 1 was found outside the facility perimeter twice on March 11, 2024. The resident has Alzheimer's Dementia and is unable to leave unassisted. The facility conducted internal investigations and increased supervision. No history of AWOL was noted for the resident.

The investigation found that the facility's perimeter gates were closed, locked, and functioning properly with no evidence of being propped open. The resident was found outside twice on the same day but was safely redirected back inside. Behavior mapping and increased monitoring were implemented. No citations were issued during the visit.

The facility was found to be clean, well-maintained, and compliant with regulations. No citations or deficiencies were observed during the visit. Resident and staff records were complete and up to date.

The facility reported two incidents involving Resident 1 touching other residents inappropriately. One-on-one caregiver support was implemented, medications were adjusted, and no further incidents were observed. No deficiencies were cited during this visit.

The visit was triggered by two reported incidents where Resident 1 touched other residents inappropriately. The facility responded by placing Resident 1 on 30-minute checks, assigning a one-on-one caregiver, and adjusting medications. The complaint was investigated and no deficiencies were found.

The investigation found that Resident 1, diagnosed with Alzheimer's Dementia, had two incidents of inappropriate touching but has not exhibited such behavior since being assigned a one-on-one caregiver. No deficiencies were cited during the visit.

The Licensing Program Analyst met with the facility administrator and health services directors, explained the purpose of the visit, and delivered an immediate exclusion letter to the administrator.

The complaint involved Staff #1 reporting that Staff #2 threw tea on Resident 1 and made contact with Resident 3. There were no witnesses. Staff #2 was suspended on 2023-08-25 and terminated on 2023-08-30. Belmont Police, Ombudsman, and required parties were notified.

The visit found no deficiencies; the reported incidents involved staff throwing tea on a resident and inappropriate contact, with the accused staff suspended and terminated. Notifications were made to police and other authorities.

The visit was triggered by a complaint regarding a resident bitten by a dog on 2023-08-10. The resident had blood on the finger but denied pain. The dog had up-to-date vaccinations and was returned to the adoption center. No prior incidents with this dog were reported.

The visit included interviews, review of the dog's vaccination records, facility policies on pets, and resident handbook. No prior biting incidents were reported, and the dog was returned to the adoption center. No deficiencies were cited during the visit.

The visit was complaint-related, following an incident where Resident 1 was bitten by a dog. The complaint was investigated and no deficiencies were found.

The visit included interviews, review of vaccination records, facility policies on pets, and resident handbook. No prior biting incidents were reported, and the dog was returned to the adoption center. No deficiencies were cited during the visit.

The visit was triggered by a complaint related to three separate incidents reported by a staff member involving interactions between Staff 2 and three residents. No citations were issued.

During the visit, documentation was collected and no citations were issued. The report was reviewed with the administrator and a copy was provided.

The visit included discussions with facility staff and review of resident files. No citations were issued. Observations included one-on-one caregiver supervision for one resident, increased medication dosage, and room relocation for the involved resident.

An immediate exclusion letter was delivered to the Assistant Director of Health Services to exclude an employee. The report was reviewed and discussed with the Assistant Director of Health Services.

The facility was found to be clean, odorless, and free from hazards with proper infection control practices observed such as COVID-19 signage, screening logs, PPE supply, and staff wearing face masks. No citations were issued during the visit.

The visit found that Resident #1, diagnosed with dementia, had prior behavioral incidents and now has a one-on-one caregiver assigned around the clock with medication adjustments and ongoing communication with the responsible parties. No citations were issued during the visit.

The visit found multiple incidents involving residents with dementia exhibiting aggressive behaviors towards each other, with behavior mapping and medication adjustments being conducted. No citations were issued during the visit.

The visit was triggered by a reported incident where Resident #1 jumped over the facility fence unassisted. The complaint was investigated and no citations were issued.

The resident was observed walking outside with a one-on-one caregiver during the visit. The facility had notified the resident's responsible party and physician, who adjusted medications. No injuries or citations were noted, and behavior mapping was ongoing.

The resident was observed walking outside with a one-on-one caregiver, no injuries were noted from the incident, and the facility had notified the resident's responsible party and physician. The physician adjusted the resident's medications and assigned a one-on-one caregiver. No citations were issued during the visit.

The visit was complaint-related, following up on incidents involving resident R1's aggressive and inappropriate behaviors and resident R3's room entry incident. No injuries were reported, and the facility took corrective actions including medication adjustments and increased supervision.

The report detailed multiple incidents involving resident R1 hitting and touching caregivers and another resident, with the facility implementing medication adjustments, frequent checks, and assigning two caregivers for care. Another incident involved resident R3 entering another resident's room with no injuries reported, and frequent checks were also implemented to prevent recurrence.

The visit was triggered by a complaint related to an incident where Resident 1 was observed kicking Resident 2. The incident was reported to the Ombudsman, Licensing, Physicians, and the resident's Responsible Party. No prior history of physical abuse was noted and the complaint was not substantiated with deficiencies.

The inspection found that the incident was a one-time altercation between two residents with dementia and behavioral disturbances, who were left alone in the dining room. The facility does not provide one-on-one care unless stated otherwise, and no deficiencies were issued.

The visit found that Resident 1 was observed kicking Resident 2, both diagnosed with Dementia with Behavioral Disturbances. The incident was a one-time altercation with no prior history of physical abuse, and no deficiencies were issued.

The facility was found to be in compliance with Title 22 regulations with no citations issued. The inspection included checks of resident rooms, fire safety equipment, emergency power, medication storage, and food supplies.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

The investigation found no evidence to substantiate the allegations. Observations showed the resident appeared clean, linens were in place, the bathroom was free of odors, and food served was fresh and adequate. The allegations were determined to be unsubstantiated.

The facility was toured including resident buildings and common areas. All safety equipment such as smoke detectors, fire panels, and carbon monoxide detectors were inspected and found operational. Resident rooms were furnished appropriately with safety features. The kitchen and food supplies were inspected with some cleaning and service scheduled. Medications were properly stored and locked. The facility was found in compliance with Title 22 regulations and no citations were issued.

The visit was complaint-related due to an unusual incident on 03/29/2021. The incident needs further investigation.

The Licensing Program Analyst interviewed the Administrator and staff who witnessed the incident, requested additional documents for review, and planned further follow-up and interviews. The incident requires further investigation.

The Licensing Program Analyst conducted a virtual tour and discussed the facility's protocols on elopement prevention, pressure injury prevention, fall prevention, resident appraisals, plan of care, physical plant safety, residents' personal rights, staff training, staff monitoring, and medication monitoring plan. The inspection will be conducted frequently as per the compliance plan.