complaint·March 26, 2025

and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined: The complaint alleges that while being transferred using a Hoyer lift, R1 fell, causing a brain hemorrhage, resulting in R1’s death. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Care Plan and Silverado policy states “Transfers – 2-person assist. Provide resident with 2-person physical assist to increase independence and ensure safety in transfers.” However, S1 admitted that although they were aware of Silverado policy and R1’s care plan, S1 did not call for assistance transferring R1 on the morning of 08/30/2024. As S1 pulled the lift back with the sling attached and R1 in the sling, S1 lost control of the lift and the lift tilted to one side. S1 admitted that due to S1’s stature and R1’s weight, S1 could not regain control of the lift, resulting in the lift falling, R1 hitting their head on the floor and causing a head injury. S1 called for assistance from the facility LVN on duty. R1 was assessed for injury and noted to be awake, but had a blank stare, was unresponsive to light and not blinking. 9-1-1 was called and R1 was taken to the hospital for further medical treatment. R1 was admitted to the hospital in critical care due to the head injury sustained at the facility. R1 was diagnosed with a subdural hematoma measuring 6 mm in maximal depth with a 2 mm midline shift to the left. R1 was discharged from the hospital to a Skilled Nursing Facility before returning to Silverado Senior Living Calabasas on 10/01/2024. R1 was admitted to hospice on the date of their return. R1 passed away under hospice care on 10/03/2024. Immediate cause of death listed on Certificate of Death was Traumatic Subdural Hematoma. Manner of death was listed as accidental as a result of injury sustained due to “fall in hospice facility” on 08/30/2024. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “neglect/lack of care leading to questionable death” is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided. and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined: The complaint alleges that inadequate staffing led to R1 falling during transfer, resulting in injury. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Although S1 was aware of both Silverado policy and R1’s care plan, on the morning of 08/30/2024, S1 chose to transfer R1 alone. S1 stated they believed other staff to be busy assisting other residents at that time and S1 did not wish to “bother them.” S1 admitted they made a mistake and should have called for a second staff to assist with the transfer. Interviews and staff schedule review indicate at the time of the incident, there were 6 total care staff, 1 (one) LVN, and 1 (one) medication technician present at the facility on the date of the incident. The census on 08/30/2024 was 52 residents. At the time of the incident, 5 (five) caregivers were each assigned to care for their own specific group of residents and the additional caregiver was working as a floater, to assist with 2-person transfers and assist as needed with residents. S1 admitted they do have the ability to call for assistance, but on the date of the incident S1 did not request assistance. Management staff did “write up” S1 as a result of the policy violation. Based on the information obtained during the investigation there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “neglect/lack of supervision – inadequate staffing to transfer resident in care, resulting in resident falling” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.