Inspection Reports for Silverado Brea Memory Care Community

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.

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.

Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of Silverado Brea LLC.

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.

An unannounced case management visit was conducted to amend findings for Complaint Control # 22-AS-20250819122622, originally delivered on August 28, 2025.

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.

The complaint finding was amended from Unsubstantiated to Unfounded.

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.

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.

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.

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.

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.

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.

The visit was an unannounced investigation of a complaint received regarding staff mismanagement of residents' medication on July 13, 2025.

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.

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.

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.

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.

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.

The visit was conducted as a Case Management visit following an Unusual Incident Report regarding a resident elopement received on January 10, 2025.

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.

An unannounced Case Management visit was conducted due to an Unusual Incident Report received by the Regional Office on December 23, 2024.

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.

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.

The visit was an unannounced Annual Required Evaluation conducted by the Licensing Program Analyst to assess compliance with regulatory standards.

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.

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.

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.

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.

The visit was an unannounced case management follow-up on an Incident Report regarding an elopement by Resident #1 on September 16, 2024.

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.

The visit was an unannounced case management follow-up on a self-reported medication error incident that occurred on July 29, 2024.

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.

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.

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.

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.

The complaint was unsubstantiated as there was insufficient evidence to prove the alleged violation occurred.

Licensing Program Analyst Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit.

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.

The visit was an unannounced complaint investigation regarding an allegation that the facility failed to provide residents' records upon written request.

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.

The complaint alleged failure to provide residents' records upon written request. The complaint was investigated and found to be unfounded.

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.

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.

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.