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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200938
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:57:33 PM


Document Has Been Signed on 09/30/2022 03:57 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:SNEE, ROBERTFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STREETTELEPHONE:
(949) 240-7200
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:90CENSUS: 76DATE:
09/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Jeff Emoruwa, Director of Health ServicesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an case management regarding an incident report for R1. LPA met with Jeff Emoruwa, Director of Health Services.

During the course of the visit LPA interviewed S1, S2 and S5. LPA collected the following documents: resident roster, physician's report; ID and emergency information, behavior mapping, comprehensive assessment and service plan, care conference sheet, and resident appraisal. LPA requested staff roster, and police report for R1.

UIR, records and interviews revealed that R1 eloped, R1 was not a flight or elopement risk. Contractors were on site and the alarm system had been disarmed by S3. S3 asked S2 to close the doors but was not aware that the alarm system had not been armed/reset. S1 stated that S2 is a new employee and the alarm system has two different codes that need to be activated. R1 wandered about two blocks away to a synagogue on Jefferson St and Berkeley police were called by an unknown person. Berkeley Police reported to S5 that R1 appeared confused, was in their custody, and returned R1 to the facility appearing uninjured. S1 completed in-service training with Plant Operations and Care Staff; all staff are responsible for disarming/arming the alarm system themselves and verifying it's operational.

No deficiencies cited, exit interview, and a copy of this report provided to Jeff Emoruwa.



SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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