Inspection Report Summary
Most inspections found no deficiencies, with the facility generally meeting regulatory standards for resident care, safety, and staff training. Several complaint investigations were unsubstantiated or unfounded, indicating that many concerns raised were not confirmed. However, there were a few substantiated deficiencies, including a medication error in July 2025 where untrained staff administered medication incorrectly, and a serious incident in April 2025 when a resident ingested a toxic substance left unsecured, resulting in harm and civil penalties. The most recent report from October 28, 2025, cited a deficiency for failing to secure exterior doors and alarms, leading to a resident elopement and a $500 fine. While these issues highlight some lapses in medication management and environment safety, the facility’s record shows improvement in other areas, and the majority of recent inspections have been free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Capacity: 70
Deficiencies: 1
Oct 28, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow-up on an Unusual Incident Report regarding a resident elopement incident that occurred on 2025-09-25.
Findings
The facility failed to secure exterior doors and alarms for dementia residents, resulting in a resident eloping from the community. An immediate $500 civil penalty was issued for this violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to ensure the facility had an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to residents at risk for elopement, resulting in a resident eloping from the community. | Type A |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tana McMillon | Regional Vice President of Operations | Met with during exit interview and discussed findings |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted inspection and signed report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 43
Capacity: 70
Deficiencies: 0
Oct 21, 2025
Visit Reason
Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of Silverado Brea LLC.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. The physical plant, fire safety equipment, medication storage, staff training, and resident care were all inspected and found satisfactory.
Report Facts
Hot water temperature range: 107.9-113.0
Fire extinguishers: 14
Fire drill date: Sep 7, 2025
Administrator certificate expiration: Nov 18, 2026
Food supply retention: 2
Food supply retention: 7
Inspection start time: 12:30
Inspection end time: 16:40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Tana McMillon | Regional Vice President of Operations | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ashiman Gill | Administrator | Facility administrator with current certificate expiring November 18, 2026 |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Sep 16, 2025
Visit Reason
An unannounced case management visit was conducted to amend findings for Complaint Control # 22-AS-20250819122622, originally delivered on August 28, 2025.
Findings
The Licensing Program Analyst explained to the Administrator that the complaint finding was amended from Unsubstantiated to Unfounded. An exit interview was conducted and a copy of the amended findings and report was provided to the facility.
Complaint Details
The complaint finding was amended from Unsubstantiated to Unfounded.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during the visit and involved in discussion of amended complaint findings. |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit and explained amended complaint findings. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Aug 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that a resident fell due to lack of care and supervision on August 19, 2025.
Findings
Based on observations, interviews, records, and video review, the allegation that a resident fell due to lack of care and supervision was found to be unfounded. The resident had a witnessed fall, appropriate staff response, and subsequent care measures were implemented.
Complaint Details
The complaint alleged that a resident fell due to lack of care and supervision. The investigation included interviews with witnesses, staff, and the resident, review of video footage, medical and incident reports, and assessment of care protocols. The allegation was determined to be unfounded.
Report Facts
Facility capacity: 70
Resident census: 49
Fall incident time: 742
Paramedics arrival time: 757
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 70
Deficiencies: 0
Jul 22, 2025
Visit Reason
The visit was an unannounced investigation into a complaint received regarding a medication error that occurred on July 13, 2025, where a resident was given the wrong medication.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that staff failed to follow reporting requirements or falsified residents' medication records. The resident who received the wrong medication remained stable with no adverse effects observed.
Complaint Details
The complaint involved allegations that staff were not following reporting requirements and that staff falsified residents' medication records. Both allegations were found to be unsubstantiated after review of records, interviews, and monitoring of the affected resident.
Report Facts
Capacity: 70
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 70
Deficiencies: 1
Jul 22, 2025
Visit Reason
The visit was an unannounced investigation of a complaint received regarding staff mismanagement of residents' medication on July 13, 2025.
Findings
The investigation substantiated the allegation that Staff #1, who was not trained or authorized to dispense medication, gave medication intended for Resident #1 to Resident #2. Resident #2 was closely monitored with no adverse effects noted. The facility was cited for failure to assist residents with self-administered medications, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated. Staff #1, not trained as a nurse or Medication Technician, mistakenly gave Resident #1's medication to Resident #2. The incident was reported, and Resident #2 was monitored with no adverse effects.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 70
Census: 48
Deficiency Type A: 1
Plan of Correction Due Date: Jul 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Named in medication mismanagement incident and exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw complaint investigation and deficiency citation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 70
Deficiencies: 1
Apr 15, 2025
Visit Reason
The visit was an unannounced case management inspection to deliver findings of an investigation into an incident involving Resident 1 (R1) who ingested a toxic substance at the facility on December 20, 2024.
Findings
The investigation substantiated that the facility failed to ensure poisonous substances were not left unattended outside locked storage, resulting in R1 ingesting epoxy resin which caused chemical burns, acute hypoxemic respiratory failure, and angioedema. Immediate civil penalties were assessed.
Complaint Details
The investigation was triggered by a complaint regarding an incident where Resident 1 ingested epoxy resin during a resident engagement activity. The complaint was substantiated based on interviews, surveillance footage, and medical records.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that poisonous substances are not left unattended outside locked storage, resulting in harm to Resident 1. | Type A |
Report Facts
Capacity: 70
Census: 36
Plan of Correction Due Date: Apr 16, 2025
Incident Date: Dec 20, 2024
Hospitalization Duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met during inspection and involved in investigation |
| Alyssa Herris | Director of Resident Engagement | Led the engagement activity during which the incident occurred |
| Elizabeth Retts | Director of Health Services | Notified immediately after the incident and involved in resident care |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced visit and investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 40
Capacity: 70
Deficiencies: 0
Jan 16, 2025
Visit Reason
The visit was conducted as a Case Management visit following an Unusual Incident Report regarding a resident elopement received on January 10, 2025.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. The resident elopement was addressed with corrective actions including staff counseling, locking the courtyard exit door, daily management checks, and installation of an audible alarm.
Report Facts
Capacity: 70
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Executive Director | Met with Licensing Program Analyst during inspection and involved in elopement incident response |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 70
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced Case Management visit was conducted due to an Unusual Incident Report received by the Regional Office on December 23, 2024.
Findings
The Licensing Program Analyst interviewed staff and resident family members, reviewed resident records, staff files, staffing schedules, and video footage related to the incident. Further investigation is needed based on observations and interviews during the visit.
Complaint Details
The visit was triggered by an Unusual Incident Report. The Licensing Program Analyst conducted interviews and reviewed documentation but indicated that further investigation is required.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Libbie Retts | Director of Health Services | Met with Licensing Program Analyst during the visit. |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 70
Deficiencies: 0
Oct 18, 2024
Visit Reason
The visit was an unannounced Annual Required Evaluation conducted by the Licensing Program Analyst to assess compliance with regulatory standards.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. The physical plant, food supply, medication storage, staff training, and resident care were all inspected and found satisfactory.
Report Facts
Fire extinguisher service date: Apr 2, 2024
Last fire drill date: Oct 3, 2024
Hot water temperature range: 107.0-109.4
Administrator certificate expiration: Mar 10, 2025
Food supply minimum days: 2
Food supply minimum days: 7
Elevators out of order: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tana McMillon | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Libbie Retts | RN, MSN, Director of Health Services | Met with Licensing Program Analyst during inspection and exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 70
Deficiencies: 1
Sep 26, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations that the facility did not safeguard resident property and that residents' needs were not being met, including failure to provide timely medical attention.
Findings
The investigation substantiated that the facility failed to safeguard resident property by not returning hearing aids after discharge, posing a potential health and safety risk. The allegations regarding unmet resident needs and untimely medical attention were found unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for failure to safeguard resident property. The allegations that resident needs were not met and medical attention was not timely were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not safeguard resident property by failing to return hearing aids to resident after discharge. | Type B |
Report Facts
Facility capacity: 70
Census: 33
Deficiencies cited: 1
Plan of Correction due date: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Vanessa Valencia | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 34
Capacity: 70
Deficiencies: 0
Sep 24, 2024
Visit Reason
The visit was an unannounced case management follow-up on an Incident Report regarding an elopement by Resident #1 on September 16, 2024.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. The resident was found within twenty-five minutes of elopement with no injuries, and staff were in-serviced on security and safety measures.
Report Facts
Staffing counts: 3
Staffing counts: 1
Staffing counts: 2
Incident response time: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during visit and involved in incident follow-up |
| Libbie Retts | Director of Health Services | Met with Licensing Program Analyst during visit and involved in incident follow-up |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Follow-Up
Census: 33
Capacity: 70
Deficiencies: 0
Sep 9, 2024
Visit Reason
The visit was an unannounced case management follow-up on a self-reported medication error incident that occurred on July 29, 2024.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. Corrective actions were taken including staff in-service training and removal of two involved employees.
Complaint Details
The visit was triggered by a medication error complaint involving Resident #1 who did not receive some medications for three days. The incident was investigated, monitored, and corrective actions were implemented. No adverse effects were observed in the resident.
Report Facts
Incident date: Jul 29, 2024
Number of staff involved: 4
Number of staff no longer employed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashiman Gill | Administrator | Met with Licensing Program Analyst during the visit and involved in incident follow-up |
| Libbie Retts | Director of Health Services | Reported the medication error and involved in incident investigation |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 70
Deficiencies: 0
Aug 8, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not answering residents' call buttons in a timely manner due to inadequate staffing.
Findings
The investigation included interviews with staff and the administrator, review of staffing schedules, and observation of call button response times. Staff denied any staffing issues, and observations showed staff responded within 5 minutes. Due to conflicting information and lack of documentation, the allegation was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated as there was insufficient evidence to prove the alleged violation occurred.
Report Facts
Capacity: 70
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Vanessa Valencia | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Annual Inspection
Census: 34
Capacity: 70
Deficiencies: 0
Oct 19, 2022
Visit Reason
Licensing Program Analyst Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility was found to be in compliance with no deficiencies noted. Observations included proper COVID-19 protocols, adequate emergency and food supplies, proper signage, and well-maintained resident rooms and common areas.
Report Facts
Number of resident files reviewed: 7
Number of fire extinguishers observed: 9
Number of bedrooms: 40
Medication supply days: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced annual visit and inspection |
| Gigi McCorkle | Administrator Specialist | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 70
Deficiencies: 0
Apr 21, 2021
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that the facility failed to provide residents' records upon written request.
Findings
The investigation found that the facility initially did not fulfill the records request due to a missing signed Guardian ad Litem form, making the request incomplete and invalid. After receiving the completed request form, the facility fulfilled the request. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged failure to provide residents' records upon written request. The complaint was investigated and found to be unfounded.
Report Facts
Facility capacity: 70
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Barrett | Licensing Program Analyst | Conducted the complaint investigation |
| Maria Kauten | Executive Director | Met with during the investigation and involved in the findings |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 70
Deficiencies: 0
Nov 16, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/18/2020 alleging insufficient staffing, failure to report incidents, resident left unsupervised, malfunctioning alert devices, staff training deficiencies, and unsafe environment concerns.
Findings
The investigation involved interviews, record reviews, and site observations. All allegations were found to be unsubstantiated due to lack of preponderance of evidence. Staffing was adequate with shift coverage during call-outs, incidents were reported regularly, the resident who left was found unharmed after using a Lyft service, alert devices were functional, and staff training records met requirements.
Complaint Details
The complaint included allegations of insufficient staff to meet residents' needs, failure to report incidents, a resident leaving unsupervised, malfunctioning alert devices, lack of staff training, and unsafe environment. All allegations were investigated and deemed unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 70
Census: 27
Staffing levels: 1
Staffing levels: 4
Staffing levels: 3
Door alarm test dates: 4
Staff training hours: 40
Staff training hours: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Barrett | Licensing Program Analyst | Conducted the complaint investigation and presented findings |
| Maria Kauten | Executive Director | Facility administrator interviewed during investigation |
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