Complaint·April 7, 2026

staff Alcohol and Substance Abuse Policy in the employee handbook, Associate Acknowledgement of policy (dated 04/30/2025, 02/23/2013, and 03/14/2025), and Torrance Police Department Case Information (dated 03/03/2026 and 03/13/2026). The investigation revealed the following: Allegation: Staff worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. The allegation alleges that staff are working while impaired, narcotics have fallen out of a staff’s pocket, and staff were observed getting high during a break. During record review, LPA received and reviewed the Alcohol and Substance Abuse Policy on page 40 of the Employee Handbook signed and dated by staff when they are hired. It states “the purpose of this policy is to inform every associate that Silverado does not condone or tolerate alcohol or drug use in the workplace. During interviews with Staff S1-S6, were asked if they have worked while under the influence, six (6) out of six (6) stated they have not worked while under the influence. Additionally, Staff S1-S6 were asked if they have observed staff working while under the influence, six (6) out of six (6) stated no, they have not observed staff working while under the influence. During interviews with Resident R1-R6, were asked if they have observed staff working while under the influence, five (5) out of six (6) stated they have not seen staff working while under the influence. One resident did not answer. During interviews with resident responsible party W1 -W3, were asked if they have observed staff working while under the influence of a mind altering substance, three (3) out of three (3) stated no, they have not observed staff working while under the influence. Allegation: Staff did not maintain facility free from hazards, resulting in a resident sustaining an injury. The allegation alleges that multiple exit doors are nonfunctional and a resident fell after tripping on a wet floor sign and fan. During the facility inspection, LPA tested all exit doors and observed the egress system and doors function properly and open as required. LPA observed the access hatches to the roof were closed and properly secured. Additionally, LPA was informed the carpets were just cleaned and LPA observed signs for “Wet Floors,” and fans against the walls in the hallways, not blocking the walkway. LPA observed all walkways and hallways were clean, clear, and free of hazards, debris, and obstructions. LPA received and reviewed Maintenance Logs that indicates what was reported that need fixed, and when and who repaired it. During interviews with Staff S1-S6, were asked how they ensure the facility is kept free from hazards, six (6) out of six (6) stated rounds are done multiple times a day by the maintenance director, and the directors to ensure there are no hazards. Additionally, Staff S1-S6, were asked if there have been any issues with the exit doors, six (6) out of six (6) stated there have been no issues with the egressed exit doors. During interviews with Residents R1-R6, were asked how the staff ensure the facility is free from hazards, five (5) out of six (6) stated the staff make sure walkways are clear, they pick up papers on the floor, and the staff will walk with the residents to make sure they get there safe. Additionally, Residents R1-R6, were asked if there have been any issues with the exit doors or the exit doors being left open, five (5) out of six (6) no, there have been no issues with the doors. One resident did not answer. During interviews with resident responsible party W1 -W3, were asked if staff ensure the facility is free from hazards, three (3) out of three (3) stated they have not observed any hazards at the facility. Allegation: Staff spoke inappropriately to a resident The allegation alleges staff spoke inappropriately to a resident, calling them an idiot and cussing at them. During the facility visit, LPA observed staff’s interactions with residents during meals, providing assistance, and activities. LPA observed the staff speaking respectfully to residents. During record review, LPA received and reviewed staff’s signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.” During interviews with Staff S1-S6, were asked if they have spoken to a resident in an inappropriate manner or have heard a staff speaking to a resident in an inappropriate manner, six (6) out of six (6) stated no, they have not spoken to a resident inappropriately or heard staff speak inappropriately to a resident. During interviews with Residents R1-R6, were asked if staff have spoken to them or another resident inappropriately, five (5) out of six (6) stated no. One (1) resident did not answer. During interviews with resident’s Responsible Party W1-W3, were asked if they heard staff speaking inappropriately to any resident, three (3) out of three (3) stated no. Allegation: Staff handled resident in a rough manner The allegation alleges that while assisting a resident up from a fall the staff handled them in a rough manner. During the facility visit, LPA observed staff assisting residents with transferring from the wheelchair to their bed. LPA observed staff using appropriate hand placement while assisting with transferring a resident. During record review, LPA received and reviewed staffs signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.” LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia. During interviews with Staff S1-S6, were asked if they have or have observed staff handle a resident in a rough manner, six (6) out of six (6) stated no, they have not. During interviews with Residents R1-R6, were asked if staff have handled them in a rough manner, five (5) out of six (6) stated no, they have not been handled in a rough manner. During interviews with resident’s Responsible Party W1-W3, were asked if they have observed staff handle a resident in a rough manner, three (3) out of three (3) stated no they have not. Allegation: Staff did not properly report incidents The allegation alleges that incident reporting was not done regarding the residents fall. LPA received and reviewed Resident Incident Log from 01/01/2026 to 03/31/2026, that indicates R1 was observed on the floor on 02/12/2026. Additionally, LPA received and reviewed Resident R1’s Progress Notes from 01/01/2026 to 03/31/2026 that indicates on 02/12/2026 R1 was observed on the floor, was assessed by LVN, assisted to a standing position, and R1 ambulated to their room without assistance. LPA observed R1’s Responsible Party was notified and R1 was on Alert Charting and had additional monitoring till 02/15/2026. Additionally, LPA received and reviewed Unusual Incident/Injury Report’s submitted to Community Care Licensing (CCL) for the month of February. The incident reports are regarding residents who were observed on the floor and were transferred to the Emergency Room for additional assessment. During interviews with Staff S1-S6, were asked if all incidents are reported to CCL, six (6) out of six (6) stated all incidents that require first aid, a transfer to the hospital, refusal of transfer to the hospital, or incidents that interrupts daily operation is reported to licensing. During interviews with Residents R1-R6 were asked if to their knowledge are incidents reported to CCL, five (5) out of six (6) stated yes, they are. One (1) resident did not answer. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated . LPA did not observe or site any deficiencies. An exit interview was conducted with Administrator, Christina Hale, and a copy of this report was provided.