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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608180
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:15:57 PM


Document Has Been Signed on 11/07/2023 04:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SILVERADO SENIOR LIVING - THE HUNTINGTONFACILITY NUMBER:
197608180
ADMINISTRATOR:ROCHELLE CARPIOFACILITY TYPE:
740
ADDRESS:1118 N STONEMAN AVETELEPHONE:
(626) 308-9777
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:62CENSUS: 51DATE:
11/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Cathy Huo, Director of Resident Engagement.TIME COMPLETED:
04:06 PM
NARRATIVE
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During the course of a complaint investigation, Licensed Program Analyst (LPA) observed that R1 did not have updated LIC602. Last one was dated 10/12/2022 which poses/posed a health and safety Hazard to resident in care.

Deficiency cited, please see 809D for details.


Exit interview conducted with Director of Resident Engagement. and copy of report, 809D and appeal rights provided.

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SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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 2


Document Has Been Signed on 11/07/2023 04:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SILVERADO SENIOR LIVING - THE HUNTINGTON
FACILITY NUMBER: 197608180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2023
Section Cited
CCR
87458(a)

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(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
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Administrator would obtain an updated phyisican report LIC 602 and provide a copy of the physician report to Licensing by POC due date.
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Resident#1 did not have a current physician report on file.

Based on file review, Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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