Inspection Reports for Silverado Belmont Hills Memory Care Community

An unannounced case management visit was conducted in relation to an incident that occurred on 2025-09-26 involving an altercation between two residents.

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

The visit was complaint-related due to an incident where Resident 1 punched Resident 2 after Resident 2 leaned over Resident 1's shoulder. Both residents have dementia and have had prior altercations. The complaint was investigated and no citations were issued.

An unannounced case management visit was conducted to follow up on an incident that occurred on 2025-08-26 involving a resident who left the community due to a gate lock failure.

The visit found that the gate locks had failed, allowing the resident to leave the facility, but no injuries occurred. The locks were repaired and all exit gates were secured and re-keyed. No citations were issued during the visit.

The visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility.

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 inspection was an unannounced case management visit conducted in relation to an incident reported on July 8, 2025, involving a resident's allegation of staff aggression.

The investigation found the allegation unsubstantiated as no staff from the relevant shift witnessed the incident. The staff member accused was suspended pending investigation, received training, and returned to work in a different neighborhood from the resident. No citations were issued during the visit.

The complaint involved Resident 1 alleging that Staff 2 was rough and pushed the resident against the wall on July 6, 2025. The allegation was unsubstantiated based on the facility's investigation and lack of witness corroboration.

An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained pressure injuries in care and was dehydrated due to staff neglect.

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 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 visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude two staff members from the facility.

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 and a copy was provided.

An unannounced case management visit was conducted in relation to an incident that occurred on 2025-04-27 involving a 1:1 caregiver preventing a resident from leaving their room.

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 inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek timely medical attention for a resident and did not properly inform the responsible party of care needed for the resident.

The investigation substantiated that staff failed to seek timely medical attention for Resident 1 after a fall on 12/23/2024, resulting in a left hip fracture. However, the allegation that staff did not properly inform the responsible party was found to be unfounded.

The complaint alleged that staff did not seek timely medical attention for a resident after a fall and did not properly inform the resident's responsible party of care needed. The allegation of failure to seek timely medical attention was substantiated, while the allegation regarding failure to inform the responsible party was unfounded.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Silverado Senior Living - Belmont Hills facility.

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.

An unannounced case management visit was conducted to follow up on an incident reported to Community Care Licensing involving Resident 1 who was found outside the facility perimeter.

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 a Case Management follow-up on a substantiated complaint allegation of neglect and lack of supervision resulting in serious bodily injuries to a resident.

The investigation found that the facility failed to conduct accurate fall risk assessments and implement appropriate care plans for a resident who sustained multiple falls, including a serious injury requiring surgery. The facility did not notify the Primary Care Physician timely and continued care based on outdated assessments.

The complaint was substantiated. The facility was cited for violating CCR Title 22, § 87464(f) Basic Services. An immediate civil penalty of $500 was issued on October 10, 2019, and an additional civil penalty of $9,500 was issued on February 16, 2024, totaling $10,000 for serious bodily injury resulting from neglect.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and overall facility conditions.

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.

An unannounced case management visit was conducted to follow up on an incident reported on December 10, 2023, involving Resident 1 touching Resident 2 inappropriately while left unattended by a private caregiver.

The facility failed to provide orientation and training to the private one-on-one agency caregiver assigned to Resident 1, resulting in Resident 1 being left unattended and observed touching Resident 2 inappropriately. This was the third such incident involving Resident 1.

An unannounced case-management visit was conducted to follow up on two incidents involving Resident 1 reported to the Community Care Licensing Division.

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 an unannounced case management visit to deliver an immediate exclusion letter to exclude an employee of the facility.

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 visit was an unannounced case management follow-up on an incident reported on 2023-08-28 involving alleged staff misconduct towards residents.

The Licensing Program Analyst discussed the reported incidents with facility administration and staff. There were no witnesses to the incidents, and the staff member involved was suspended and later terminated. No deficiencies were cited during the visit.

The complaint involved Staff 2 allegedly throwing a cup of tea on Resident 1 and making contact with Resident 3. Staff 2 was suspended on 2023-08-25 and terminated on 2023-08-30. Belmont Police, Ombudsman, and required parties were notified.

An unannounced case-management visit was conducted to follow up on an incident reported to the Community Care Licensing Division on 2023-08-17 involving a resident bitten by a dog.

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 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.

An unannounced case management visit was conducted to follow up on an incident reported to the Community Care Licensing on 2023-07-20 involving three separate incidents between a staff member and three different residents.

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 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.

An unannounced case management visit was conducted to follow up on an incident that occurred on April 22, 2023, involving two residents.

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 unannounced case management visit was conducted to amend a previous licensing report related to complaint control number 14-AS-20220216135656, specifically addressing reporting requirements violations.

The facility failed to provide required reports (LIC624 and SOC341) within regulatory timeframes for an alleged abuse incident that occurred on February 13, 2022, resulting in a cited deficiency under Residential Care Elderly California Code of Regulations, Title 22, Division 6.

This visit was complaint-related, amending a prior licensing report for complaint control number 14-AS-20220216135656. The deficiency relates to failure to timely report an alleged abuse incident. Substantiation status is not explicitly stated.

The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee of the facility.

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.

An unannounced annual infection control inspection was conducted to evaluate infection control practices and compliance with COVID-19 protocols.

The facility was found to be clean, odorless, and free from hazards with proper infection control practices observed, including COVID-19 signage, screening logs, PPE supply, face coverings for staff, and locked storage for medications and chemicals. No citations were issued during the visit.

Unannounced case management visit to follow up on a previous visit regarding an un-witnessed incident involving Resident #1 and Resident #2 that occurred on September 25, 2022.

Resident #1 has a history of aggressive and inappropriate behaviors towards other residents, causing the facility environment to be uncomfortable for others. Despite interventions, Resident #1 has recurring incidents. A deficiency related to personal rights of residents was cited.

An unannounced case management visit was conducted to follow up on an incident reported to the Community Care Licensing Division on October 3, 2022, involving two residents.

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.

An unannounced case management visit was conducted to follow up on incidents reported to the Community Care Licensing Division involving resident altercations and behaviors.

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.

An unannounced case management visit was conducted to follow up on an incident reported on September 9, 2022, involving a resident who jumped over the facility fence.

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 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.

An unannounced case management visit was conducted to follow up on an incident reported to the Community Care Licensing Division involving Resident #1 exhibiting unusual behavior.

The investigation found that Resident #1, diagnosed with dementia, was observed laying beside another resident due to lack of staff supervision. This was the second such incident involving Resident #1. A deficiency was cited for failure to provide adequate care and supervision.

The visit was complaint-related, following an incident reported on July 15, 2022, involving Resident #1's unusual behavior. The complaint was substantiated by the findings of inadequate supervision.

An unannounced case management visit was conducted to follow up on an incident involving Resident #1 eloping from the facility on July 11, 2022.

The investigation found that Resident #1, diagnosed with Alzheimer's dementia and with a history of elopement, climbed over the facility gate and left unassisted. The facility notified the responsible party and physician, who adjusted medications and assigned a one-on-one caregiver. A deficiency was cited related to care and supervision.

An unannounced case management visit was conducted to follow up on an incident reported on June 24, 2022, regarding a resident possibly eating cat food.

The facility did not ensure basic services were met due to lack of supervision, as Resident #1 possibly ate cat food with no witnesses to confirm. The facility moved the resident to a higher level of care neighborhood and removed cat food bowls to prevent further incidents.

The visit was complaint-related, following an incident report that Resident #1 may have eaten cat food. The facility was unaware if the resident ate the cat food due to no witnesses. The complaint was investigated during the visit.

An unannounced case management visit was conducted to follow up on incidents reported to the Community Care Licensing Division involving resident behaviors and interactions.

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 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 inspection was an unannounced case management visit conducted due to an incident where a resident with dementia was observed leaving the facility unassisted on May 13, 2022.

The facility was found to have an absence of supervision resulting in a resident leaving the facility unassisted, posing a potential health and safety risk. The latch on the gate may not have been properly secured, and the facility took corrective actions after the incident.

The visit was complaint-related due to an incident where Resident (R1) with dementia left the facility unassisted. The complaint was substantiated with findings of insufficient supervision and a repeat violation resulting in a $500 civil penalty assessed.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not following COVID protocols and lacked sufficient staff to provide care and supervision for COVID positive residents in the designated isolation unit.

The investigation substantiated that the facility failed to follow COVID protocols by not isolating COVID positive residents in the designated isolation unit, posing a potential health and safety risk. However, the allegation that the facility lacked enough staff to provide care and supervision for COVID positive residents in the isolation unit was unsubstantiated.

The complaint was substantiated regarding failure to follow COVID protocols and isolation of COVID positive residents. The complaint about insufficient staffing for COVID positive residents in the isolation unit was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations received on 02/16/2022 regarding a private caregiver not associated with the facility while providing care, failure to report incidents to Licensing as required, and physical abuse allegations involving a private caregiver and a resident.

The investigation substantiated that the private caregiver was never associated with the facility and that the facility failed to report an incident of alleged abuse within required timeframes, resulting in civil penalties. The allegation that the private caregiver kicked a resident was unsubstantiated, and the allegation that the caregiver was un-fingerprinted was unfounded.

The complaint investigation was substantiated for the private caregiver not being associated with the facility and failure to report incidents to Licensing as required. The allegation that the private caregiver kicked a resident was unsubstantiated, and the allegation that the caregiver was un-fingerprinted was unfounded.

An unannounced case management visit was conducted regarding an Incident Report involving an unwitnessed altercation between two residents on January 19, 2022.

The investigation found that two residents with dementia were left unsupervised during the altercation, violating staffing requirements. The facility failed to provide sufficient supervision despite awareness of aggressive behaviors, resulting in a deficiency citation.

The visit was complaint-related due to an incident involving two residents in an unwitnessed altercation. It was substantiated that there was insufficient staff supervision during the incident.

An unannounced Case Management visit was conducted regarding an Incident Report received on November 10, 2021, involving an altercation between two residents.

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 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.

Unannounced visit/investigation of a complaint received on 07/07/2021 regarding allegations of inadequate resident hygiene assistance, dirty bathroom, lack of linens, and poor food quality.

The investigation found that the resident was clean and hygiene needs were mostly met, the resident's bathroom was not malodorous or dirty, linens were in place, and food served was fresh and of good quality. The allegations were unsubstantiated due to lack of preponderance of evidence.

Complaint investigation was unsubstantiated. Allegations included staff not assisting resident with hygiene needs, dirty and malodorous bathroom, lack of linens, and poor food quality. No violations were found.

Unannounced visit/investigation of a complaint received on 07/14/2021 regarding a resident sustaining unexplained injuries while in care.

The investigation found that the resident had an unexplained injury discovered during observation rounds, with no direct evidence to substantiate the allegation. The facility reported the fall and the injury was diagnosed at the hospital. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Complaint was unsubstantiated. The allegation was that a resident sustained unexplained injuries while in care, but there was insufficient evidence to prove the violation occurred.

An unannounced prelicensing inspection visit was conducted to evaluate the facility's compliance with regulations and readiness for licensing.

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.

An unannounced follow-up case management inspection was conducted regarding an unusual incident that occurred on 2021-03-29, reported through an unusual incident report from the facility.

The licensee failed to protect residents' personal rights, posing an immediate health, safety, and personal rights risk. Staff was observed by another staff being abusive to residents, resulting in a cited deficiency under California Code of Regulations, Title 22, Division 6.

The inspection was conducted to obtain information regarding an unusual incident that occurred on 2021-03-29.

The Licensing Program Analyst interviewed the Administrator and staff who witnessed the incident, requested additional documents for review, and indicated that the incident needs further investigation.

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

An unannounced complaint investigation was conducted based on complaints received regarding incidents on 12/19/2019 and 12/21/2019 involving resident injuries and lack of supervision.

The investigation substantiated that the facility failed to provide adequate supervision to residents, resulting in injuries and violations of residents' personal rights. Staff were not present on the floor during incidents, leading to resident injuries and safety risks.

The complaint was substantiated. Incidents involved residents R1, R2, R3, and R4 where lack of supervision led to injuries and violations of personal rights. An immediate civil penalty of $500 was assessed for the violation resulting in injuries to a resident in care.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2020-01-13 alleging that the facility failed to provide adequate care and supervision to a resident resulting in death.

The investigation substantiated that the facility failed to provide adequate care and supervision to resident R1, who exhibited aggressive and combative behavior. The 1:1 caregiver assigned was not adequately trained and left the resident unsupervised, leading to R1 falling while chasing staff and subsequently dying from blunt force injuries. An immediate civil penalty of $500 was assessed.

The complaint was substantiated. The allegation was that staff failed to provide adequate care and supervision to a resident resulting in death. The investigation included review of medical records, interviews, and a virtual tour. The resident's aggressive behavior was not properly managed, leading to the fatal incident.

This unannounced case management monitoring inspection was conducted to ensure compliance with the compliance plan discussed with the Licensee on 02/29/2020 during a Non-compliance meeting held at the San Bruno Office.

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.