197608180-9-16-2024-28-AS-ALOZ-D96TFV-20240916144210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608180
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:42:23 PM

Document Has Been Signed on 09/16/2024 02:42 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 HUNTINGTON		FACILITY NUMBER:	197608180
ADMINISTRATOR:	ROCHELLE CARPIO		FACILITY TYPE:	740
ADDRESS:	1118 N STONEMAN AVE		TELEPHONE:	(626) 308-9777
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	62	CENSUS: 55	DATE:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Arienne Ghammangne , Director of Health Services and Rochelle Carpio, Administrator.		TIME COMPLETED:	02:49 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Director of Health services Arienne Ghammangne and Administrator Rochelle Carpio arrived a short time later and assisted with the visit. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for ten (10) resident is approved.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:

The facility consists of a 2 story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices, and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected random rooms - (rooms #157, #159, #161, #204, #203, and #223) to measure the hot water temperature.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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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Document Has Been Signed on 09/16/2024 02:42 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: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. the water at the facility measured 93.7 to 122.0 in random rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Administrator will adjust water and keep a log for seven (7) days and send to LPA as proof of correction. Civil penalties issued for repeat violation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2024 02:42 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: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Facility front side fire door is not operating as it should, it will not open. Call cord in room 157 needs repair, and there is a leak in the food storage room which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Administrator will repair the fire door, the call cord in room 157 and the water leak in the food storage room. Facility will send proof of repairs to LPA. Facility reported the fire door to fire department today. per Administrator. Facility repaired fire door and call cord during visit. Only thing pending is the leak in food storage room.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 09/16/2024

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The temperatures measured between 93.7-122 degrees F which is not the required range of 105-120 degrees F. The supply of dishes/cups is adequate. During today's visit. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The facility is equipped with a centralized sprinkler system. The north fire door was tested and does not operate. LPA asked facility to report to Fire Department and CCL and facility agreed.

Staffing:

There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Administrator Rochelle Carpio certificate expires on 01/21/2025

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the entrance.

A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

(continued)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 09/16/2024

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Food Service:

Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Incident Medical and Dental:

Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders.

Medical and dental transportation is provided by family, transportation services, or staff.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. LIC610 needs to be updated when all staff are trained on shut of utilities.

Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files.

Per California Code of Regulations, Title 22, deficiencies were cited. Technical Advisory provided.

Exit interview was conducted with staff. A copy of the report and appeal rights were issued.

Civil penalties issued for repeat violation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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