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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200938
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:24:12 PM


Document Has Been Signed on 04/19/2024 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SILVERADO SENIOR LIVING-BERKELEYFACILITY NUMBER:
019200938
ADMINISTRATOR:EMORUWA, JEFFREY OFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STREETTELEPHONE:
(949) 240-7200
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:90CENSUS: 79DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jeffrey Emoruwa, AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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On 4/19/2024 at 9:20AM, Licensing Program Analysts (LPAs) G. Luk and L. Holmes arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Administrator, Jeffrey Emoruwa and explained the purpose of the visit. The facility’s fire clearance was approved for 90 non-ambulatory residents of which 62 may be bedridden and 20 residents may be under hospice care.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication cart. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 5/2/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility purchase food supplies 2-3 times a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 38 degrees F. Hot water temperature was measured at 106.5 degrees F in a resident's bathroom sink. Grab bars for each shower and toilet were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 4/14/2024.

LPAs reviewed 5 resident records and 5 staff records starting at 11:30AM. LPAs conducted interviews with 4 residents and 4 staff during inspection. LPAs also reviewed a sample of resident's medications and MAR (Medication Administration Record).

At 12:24PM, LPAs observed residents (R1, R2, R3, R4, R5) does not have current medical assessments on file.

(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SILVERADO SENIOR LIVING-BERKELEY
FACILITY NUMBER: 019200938
VISIT DATE: 04/19/2024
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At 1:30PM, LPAs observed S2, S3, and S4 does not have current First Aid training on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Jeffrey Emoruwa. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/19/2024 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SILVERADO SENIOR LIVING-BERKELEY
FACILITY NUMBER: 019200938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessments for residents (R1, R2, R3, R4, R5) and submit copies to CCLD by POC date.
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current First Aid training for S2, S3, and S4 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator has agreed to obtain current First Aid training for staff (S2, S3, S4) and submit copies to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3