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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 04:18:22 PM


Document Has Been Signed on 09/30/2022 04:18 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Jeff Emoruwa, Director of Health ServicesTIME COMPLETED:
04:30 PM
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On 09/30/22 at 03:05 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one receptionist upon entry and explained the purpose of the visit. Jeff Emoruwa, Director of Health Services was present at the front desk.

Facility has a COVID-19 mitigation plan on file. LPA obtained a resident roster and staff roster. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, kitchen, and storage. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Administrator posted 20 seconds hand washing signs in the kitchen and continues to maintain isolation carts for infection control. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally stored and located inside the facility that is accessible to Care Staff. Hot water temperature in the shared residents' bathroom was measured at 114.5 degree Fahrenheit (F) and the facility's temperature was 72 degree (F). Fire extinguisher was observed full and last inspected on 03/22/2022. Smoke/Carbon Monoxide detectors were observed operational.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided to Jeff Emoruwa, Director of Health Services.
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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