Inspection Reports for Silverado Belmont Hills Memory Care Community
CA, 94002
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated. The most recent report from October 8, 2025, was complaint-related but had no deficiencies, focusing on managing resident altercations with dementia. Past deficiencies primarily involved care and supervision issues, including failure to prevent resident elopements, inadequate staff training, and lapses in timely medical attention, some resulting in civil penalties totaling $10,000. Enforcement actions included immediate exclusion letters for staff and fines related to serious bodily injury and reporting violations. The facility has shown some improvement recently, with no citations in the latest visits despite ongoing challenges managing residents with behavioral issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
79% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 88
Capacity: 112
Deficiencies: 0
Date: Oct 8, 2025
Visit Reason
An unannounced case management visit was conducted in relation to an incident that occurred on 2025-09-26 involving an altercation between two residents.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the investigation and discussed the incident. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 89
Capacity: 112
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
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.
Findings
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.
Report Facts
Incident date: Aug 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during visit and provided information about the incident and facility locks |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Monitoring
Census: 88
Capacity: 112
Deficiencies: 0
Date: Aug 5, 2025
Visit Reason
The visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit and received the immediate exclusion letter. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the immediate exclusion letter. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 112
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 112
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amyda Astrero | Director of Health Services | Met during the visit and involved in the investigation and training related to the complaint |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 112
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 112
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during the investigation and reviewed findings |
| Robert Snee | Administrator | Facility administrator named in the report header |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 94
Capacity: 112
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude two staff members from the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during the visit and received the exclusion letter. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Robert Snee | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Census: 91
Capacity: 112
Deficiencies: 0
Date: May 27, 2025
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit and involved in the incident investigation. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 112
Deficiencies: 1
Date: Feb 25, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Licensee failed to seek timely medical attention after Resident 1 had a fall and complained of pain, resulting in a fractured left hip.
Report Facts
Civil penalty amount: 500
Capacity: 112
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the investigation and involved in findings. |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit. |
| April Cowan | Licensing Program Manager | Oversaw the licensing program and signed the report. |
Inspection Report
Annual Inspection
Census: 81
Capacity: 112
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Silverado Senior Living - Belmont Hills facility.
Findings
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.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Fire extinguisher service date: 10
Water temperature range: 105
Water temperature range: 115
Perishable food storage duration: 2
Non-perishable food storage duration: 7
Emergency drill frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during inspection and discussed visit purpose |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Follow-Up
Census: 75
Capacity: 112
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
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.
Findings
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.
Report Facts
Incident time: 1205
Incident time: 1825
Status check interval: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during visit and involved in incident follow-up |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during visit and involved in incident follow-up |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 112
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide proper care and supervision resulting in multiple falls and serious bodily injury to a resident.
Report Facts
Civil penalty amount: 10000
Immediate civil penalty: 500
Additional civil penalty: 9500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met during the visit and acknowledged receipt of appeal rights. |
| Amyda Astrero | Director of Health Services | Met during the visit. |
| Komal Charitra | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 112
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and overall facility conditions.
Findings
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.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Fire extinguisher service date: 202310
Water temperature range (degrees F): 112
Water temperature range (degrees F): 118.9
Facility temperature (degrees F): 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during inspection |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 70
Capacity: 112
Deficiencies: 1
Date: Dec 19, 2023
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failed to provide orientation/training to the private one-on-one agency staff member assigned to Resident 1, resulting in Resident 1 being left unattended and observed touching another resident inappropriately.
Report Facts
Capacity: 112
Census: 70
Deficiency count: 1
Plan of Correction Due Date: Dec 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met during the visit and involved in interviews |
| Amyda Astrero | Director of Health Services | Met during the visit and involved in interviews |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
| Cara Smith | Licensing Program Manager | Supervisor and reviewer of the report |
Inspection Report
Follow-Up
Census: 69
Capacity: 112
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
An unannounced case-management visit was conducted to follow up on two incidents involving Resident 1 reported to the Community Care Licensing Division.
Findings
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.
Report Facts
Incident dates: 2
Check frequency: 30
Time caregiver assigned: 1830
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met during the visit and discussed incidents |
| Amyda Astrero | Director of Health Services | Met during the visit and discussed incidents; responsible for setting up re-assessment |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case-management visit |
| Cara Smith | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 66
Capacity: 112
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
The visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude an employee of the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit and received the immediate exclusion letter. |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during the visit. |
| Hazel Yabut | Assistant Director of Health Services | Met with Licensing Program Analyst during the visit. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the immediate exclusion letter. |
| Cara Smith | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
The visit was an unannounced case management follow-up on an incident reported on 2023-08-28 involving alleged staff misconduct towards residents.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 112
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during visit and involved in incident discussion |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during visit and involved in incident discussion |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Aug 18, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit and provided information regarding the incident. |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during the visit and provided information regarding the incident. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case-management visit. |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 69
Capacity: 112
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
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.
Complaint Details
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.
Findings
During the visit, documentation was collected and no citations were issued. The report was reviewed with the administrator and a copy was provided.
Report Facts
Number of incidents reported: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during the visit |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cara Smith | Licensing Program Manager | Named in the report header |
Inspection Report
Follow-Up
Census: 64
Capacity: 112
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident that occurred on April 22, 2023, involving two residents.
Findings
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.
Report Facts
Capacity: 112
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met during the visit and involved in incident discussion |
| Amyda Astrero | Director of Health Services | Met during the visit and involved in incident discussion |
| Hazel Yabut | Assistant Director of Health Services | Met during the visit and involved in incident discussion |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide LIC624 and SOC341 reports to the Department within regulatory timeframes for the incident of alleged abuse on February 13, 2022.
Report Facts
Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during the visit and discussed the report |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Cara Smith | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 60
Capacity: 112
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee of the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hazel Yabut | Assistant Director of Health Services | Met with Licensing Program Analyst during the visit and received the exclusion letter. |
Inspection Report
Annual Inspection
Census: 60
Capacity: 112
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
An unannounced annual infection control inspection was conducted to evaluate infection control practices and compliance with COVID-19 protocols.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Administrator | Met with Licensing Program Analyst during inspection and provided screening log documentation. |
| Amyda Astrero | Director of Health Services | Met with Licensing Program Analyst during inspection and reviewed report. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced annual infection control inspection. |
| Cara Smith | Licensing Program Manager | Reviewed the report. |
Inspection Report
Follow-Up
Census: 69
Capacity: 112
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
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.
Findings
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.
Deficiencies (1)
Violation of 87468.1 Personal Rights of Residents in All Facilities: Residents must be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The facility environment is not comfortable for other residents due to Resident #1's inappropriate behaviors.
Report Facts
Capacity: 112
Census: 69
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amyda Astrero | Director of Health Services | Met during the visit and involved in discussion of findings |
| Robert Snee | Administrator | Joined during the visit and involved in discussion of findings |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
| Cara Smith | Licensing Program Manager | Conducted the inspection visit and supervisor |
Inspection Report
Follow-Up
Capacity: 112
Deficiencies: 0
Date: Oct 10, 2022
Visit Reason
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.
Findings
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.
Report Facts
Facility capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amyda Astrero | Director of Health Services | Met during the visit and involved in care discussions |
| Hazel Yabut | Assistant Director of Health Services | Met during the visit and involved in care discussions |
Inspection Report
Census: 70
Capacity: 112
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on incidents reported to the Community Care Licensing Division involving resident altercations and behaviors.
Findings
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.
Report Facts
Capacity: 112
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amyda Astrero | Director of Health Services | Met during the visit and involved in discussion of incidents and findings |
| Hazel Yabut | Assistant Director of Health Services | Met during the visit and involved in discussion of incidents and findings |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jackie Jin | Licensing Program Manager | Report reviewed with this manager |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Census: 69
Total Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
| Hazel Yabut | Assistant Director of Health Services | Met with during the visit and involved in incident follow-up |
| Robert Snee | Administrator | Met with during the visit and involved in incident follow-up |
| Amyda Astrero | Director of Health Services | Joined the visit and provided information on incident follow-up |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 1
Date: Jul 19, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide basic services including care and supervision as required by regulation, evidenced by staff's failure to prevent Resident #1 from entering another resident's room and laying beside them.
Report Facts
Plan of Correction Due Date: Jul 26, 2022
Facility Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Interim Administrator | Met with Licensing Program Analyst during the visit and discussed findings |
| Kate Rickard | Director of Resident and Family Services | Met with Licensing Program Analyst during the visit and discussed findings |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Capacity: 112
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident involving Resident #1 eloping from the facility on July 11, 2022.
Findings
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.
Deficiencies (1)
Violation of Basic Services regulation: Care and supervision requirements were not met as Resident #1 was able to leave the facility unassisted despite known elopement risk and diagnosis.
Report Facts
Plan of Correction Due Date: Jul 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Miller | Staffing Coordinator | Met with Licensing Program Analyst during visit |
| Kate Rickard | Director of Resident and Family Services | Joined visit and reviewed report |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
| Julio Montes | Licensing Program Manager | Supervisor and reviewer of the report |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility did not ensure basic services were met due to lack of supervision, with Resident #1 possibly eating cat food, posing potential health, safety, and personal rights risks.
Report Facts
Total licensed capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hazel Yabut | Assistant Director of Health Services | Met during the visit and involved in discussion of the incident and findings |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Julio Montes | Licensing Program Manager | Named as Licensing Program Manager overseeing the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 112
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on incidents reported to the Community Care Licensing Division involving resident behaviors and interactions.
Complaint Details
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.
Findings
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.
Report Facts
Incidents reported: 3
Facility capacity: 112
Resident census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hazel Yabut | Assistant Director of Health Services | Met with Licensing Program Analyst during the visit and discussed incidents and corrective actions |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 1
Date: May 24, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary care and supervision, resulting in a resident with dementia leaving the facility unassisted.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Plan of Correction Due Date: May 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Snee | Interim Administrator | Met with Licensing Program Analyst during the visit and reviewed report |
| Glynis Marcantel | Director of Health Services | Joined Licensing Program Analyst during the visit and reviewed report |
| Julio Montes | Licensing Program Manager | Supervisor named in the report |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 1
Date: May 5, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to isolate COVID positive residents in the designated isolation unit, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 112
Census: 66
Plan of Correction Due Date: May 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Julio Montes | Licensing Program Manager | Oversaw the complaint investigation |
| Robert Snee | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Glynis Marcantel | Director of Health Services | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 112
Deficiencies: 2
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to associate a private caregiver who was fingerprint cleared to work at the facility.
Facility failed to report an incident of suspected physical abuse to Licensing within 24 hours and failed to submit a written report within 7 days as required.
Report Facts
Civil penalty amount: 1000
Capacity: 112
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Julio Montes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Glynis Marcantel | Director of Health Services | Facility representative met with during the investigation and named in findings. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 1
Date: Feb 24, 2022
Visit Reason
An unannounced case management visit was conducted regarding an Incident Report involving an unwitnessed altercation between two residents on January 19, 2022.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Personnel Requirements: Facility personnel shall at all times be sufficient in numbers to provide the services necessary to meet resident needs. The facility failed to provide adequate supervision to residents with known aggressive behaviors.
Report Facts
Capacity: 112
Census: 66
Plan of Correction Due Date: Mar 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor of the inspection |
| Glynis Marcantel | Director of Health Services | Met with Licensing Program Analyst during the visit |
| Diane Sapienza-Boundy | Director of Resident and Family Services | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 0
Date: Nov 15, 2021
Visit Reason
An unannounced Case Management visit was conducted regarding an Incident Report received on November 10, 2021, involving an altercation between two residents.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Newman | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Glynis Marcantel | Director of Health Services | Joined the visit shortly after it began and provided information about the incident. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Nov 12, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 112
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and made facility observations |
| Brenda Chan | Licensing Program Manager | Reviewed the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Nov 12, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 07/14/2021 regarding a resident sustaining unexplained injuries while in care.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 14-AS-20210714115037
Facility Capacity: 112
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 69
Capacity: 112
Deficiencies: 0
Date: Nov 12, 2021
Visit Reason
An unannounced prelicensing inspection visit was conducted to evaluate the facility's compliance with regulations and readiness for licensing.
Findings
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.
Report Facts
Water temperature: 116
Water temperature: 117
Water temperature: 108
Water temperature: 115
Facility capacity: 112
Resident census: 69
Fire panel inspection date: Nov 1, 2021
Sprinkler inspection date: Nov 2, 2021
Fire extinguisher inspection date: 202110
Emergency generator power duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glynis Marcantel | Director of Health Services | Met with Licensing Program Analysts during inspection |
| Gary | Director of Plant Operations | Met with Licensing Program Analysts during inspection |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 70
Capacity: 112
Deficiencies: 1
Date: Apr 30, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Residents were not free from punishment, humiliation, intimidation, abuse, or other punitive actions such as withholding residents’ money or interfering with daily living functions. Staff was observed being abusive to residents.
Report Facts
Capacity: 112
Census: 70
Plan of Correction Due Date: May 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan D Newman | Administrator | Administrator interviewed and provided documents during inspection |
| Shabana Buksh | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 112
Deficiencies: 0
Date: Apr 7, 2021
Visit Reason
The inspection was conducted to obtain information regarding an unusual incident that occurred on 2021-03-29.
Complaint Details
The visit was complaint-related due to an unusual incident on 03/29/2021. The incident requires further investigation.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan D Newman | Administrator | Interviewed by Licensing Program Analyst regarding the unusual incident. |
| Shabana Buksh | Licensing Program Analyst | Conducted the unannounced case management inspection and interviews. |
| Brenda Chan | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 112
Deficiencies: 1
Date: Dec 18, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to deliver care, supervision, and services that meet individual resident needs; staff was not present on the floor at the time of incidents resulting in injuries and safety risks.
Report Facts
Capacity: 112
Census: 89
Immediate Civil Penalty: 500
Plan of Correction Due Date: Due date 12/22/2020 for plan of correction submission
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shabana Buksh | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation |
| Cherese Holland | Administrator | Facility administrator involved in discussion of findings |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 112
Deficiencies: 1
Date: Dec 18, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to deliver care, supervision and services that met the individual needs of resident (R1), resulting in R1's fall and death due to injuries.
Report Facts
Capacity: 112
Census: 89
Civil penalty: 500
POC Due Date: Dec 22, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shabana Buksh | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in relation to the investigation and report |
| Joan Newman | Facility administrator who participated in the investigation and virtual tour | |
| Cherese Holland | Administrator | Facility administrator named in report header |
Inspection Report
Monitoring
Census: 89
Capacity: 112
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Newman | Executive Director | Discussed facility protocols during the inspection. |
| Glynis Marcantel | Director of Health Service | Provided a virtual tour of the facility. |
| Shabana Buksh | Licensing Program Analyst | Conducted the unannounced case management inspection. |
| Brenda Chan | Licensing Program Manager | Named in the report header. |
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