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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608180
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:43:16 PM


Document Has Been Signed on 10/26/2023 04:43 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: 52DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Arienne Ghammangne, StaffTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/26/23. LPA met with the Director of Health Services, Arienne Ghammangne, and explained the reason for the visit today.
The facility is licensed to serve 62 bedridden residents ages 60 and above and provides dementia care. The hospice waiver is approved for 10 residents.

LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility has sufficient PPE supplies and had submitted the Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 52 residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 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 #121, #119, #157, #163, #216, #221, #256, #260) to measure the hot water temperature. 4 out of the 8 rooms had temperatures between 136-137 degrees F which is over the required range of 105-120 degrees F. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Incidental Medical & Dental: The medications are centrally stored in the wellness office. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician.
A deficiency is being issued today. An exit interview was held and a copy of this report along with appeal rights were given to administrator Carpio.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 10/26/2023 04:43 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which 4 out of the 8 rooms' hot water temperature were over 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The administrator shall ensure the hot water temperature is within the range of 105-120 degrees F. A log of the hot water temperature shall be submitted to LPA by 10/27/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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