Inspection Reports for Silverado Beverly Place Memory Care Community

The visit was an unannounced case management inspection conducted in reference to an incident where a resident eloped from the facility unsupervised on June 18, 2025.

The facility failed to provide necessary supervision to Resident #1, who eloped from the community unattended, posing a potential health and safety risk. Deficiencies were observed related to personnel requirements and citations were issued.

The complaint was substantiated based on the incident report and investigation of Resident #1's elopement on June 18, 2025.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.

The facility was found to be clean, sanitary, and appropriately furnished with adequate safety measures in place. However, discrepancies were found in medication administration documentation for two residents, resulting in a cited deficiency.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff behavior posed a risk to a resident and that staff forced a resident to take medication without consent.

The investigation included interviews with residents, staff, and witnesses, as well as a review of medical and personnel records. The allegations were found to be unsubstantiated due to insufficient evidence, with residents and staff denying the claims and confirming appropriate medication administration and staff behavior.

The complaint alleged that staff behavior posed a risk to a resident and that staff forced Resident #1 to take medication without informing them. The investigation found no evidence to support these allegations, and they were determined unsubstantiated.

An unannounced case management visit was conducted regarding the relocation of 45 residents from Silverado Senior Living—Calabasas to Silverado Senior Living-Beverly Place due to mandatory evacuation orders from a Fire Advisory.

A health and safety check was conducted with no concerns observed. The facility was found to have sufficient beds, supplies, food, medications, and emergency equipment to accommodate the relocated residents. Rooms inspected were in compliance with Title 22 regulations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-12-19 regarding multiple allegations of staff misconduct and inadequate care at Silverado Senior Living-Beverly Place.

The investigation reviewed multiple allegations including rough handling of residents, unmet incontinence and dietary needs, failure to monitor residents' condition changes, lack of clean linens, and failure to report incidents. After interviews, record reviews, and observations, the Department found insufficient evidence to substantiate any of the allegations, resulting in an unsubstantiated complaint report.

The complaint included six main allegations: 1) Staff handled residents roughly, 2) Staff did not ensure a resident's incontinence needs were met, 3) Staff did not ensure residents' dietary needs were met, 4) Staff did not monitor residents for changes in condition, 5) Staff did not provide residents with clean linen, and 6) Staff did not report incidents to appropriate parties. The investigation involved interviews with staff, residents, and a witness, as well as review of service plans, incident reports, dietary reports, and schedules. The allegations were found unsubstantiated due to lack of sufficient evidence.

The visit was conducted as a Case Management site visit to ascertain information pertaining to a Licensee-initiated Incident Report regarding an incorrect dosage of medication administered to a resident on 2024-09-06.

The investigation found that a resident received an incorrect dosage of Ativan from a hospice nurse, but the facility staff followed physician instructions and monitored the resident. No deficiencies were observed and no citations were issued.

The visit was complaint-related due to an incident where resident #1 received an incorrect dosage of Ativan (2.5 mg instead of 0.025 mg) from a hospice nurse. The incident was reported and managed with notification to the health services director, physician, and family. The physician indicated the dosage would not lead to the resident's demise.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/01/2022 regarding medication mishandling, understaffing, and incomplete admission documents at Silverado Senior Living-Beverly Place.

The investigation found no preponderance of evidence to substantiate the allegations. Residents and staff denied the claims of medication mishandling, understaffing, and incomplete admission documents. The Licensing Program Analyst observed appropriate medication administration, adequate staffing ratios, and proper admission document distribution.

The complaint involved three allegations: 1) Facility staff mishandled resident's medications, 2) Facility is understaffed, and 3) Incomplete admission documents. All allegations were found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced annual random site visit conducted to evaluate compliance with regulatory standards using the CARE Inspection Tool.

The facility was found to be in compliance with no deficiencies observed. The environment was safe, well-maintained, and adequately stocked, with proper infection control practices and emergency preparedness measures in place.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/28/2023 regarding staff not intervening in resident-on-resident altercations and staff not ensuring that a resident received medical attention while in care.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents did not confirm that resident-on-resident altercations occurred without staff intervention or that medical attention was not provided. The allegation was therefore unsubstantiated.

The complaint alleged that staff did not intervene in resident-on-resident altercations and did not ensure that a resident received medical attention after being injured. The investigation included interviews with staff, residents, and a witness, as well as review of relevant documents. The findings were unsubstantiated due to insufficient evidence.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for Silverado Senior Living-Beverly Place.

The facility was found to be in good condition with no deficiencies noted. All resident rooms, bathrooms, and common areas were inspected and found to be properly maintained. Infection control practices, medication administration records, and safety equipment were all in order.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-06-07 regarding safety concerns, unexplained bruising, and staff training at the facility.

The investigation found no evidence or witnesses to support the allegations. Interviews with residents, staff, and a conservator, as well as document reviews and a plant inspection, indicated the facility provides a safe environment, residents did not have unexplained bruising, and staff received proper training. All allegations were unsubstantiated.

The complaint investigation was unsubstantiated for all allegations: unsafe environment, unexplained bruising, and improper staff training. The preponderance of evidence standard was not met to prove violations.

The visit was conducted as a pre-licensing evaluation for an initial license application for a Residential Care for Elderly facility.

The facility was evaluated for compliance with licensing requirements including capacity, room arrangements, safety features, and emergency preparedness. No corrections were required at the time of the evaluation.