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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 06:30:05 PM

Document Has Been Signed on 11/07/2023 06:30 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:
11/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arienne Ghammangne, StaffTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with Director of Resident Engagement, Cathy Huo, and explained the reason for the visit.

During the visit today, LPA completed the remainder of the inspection and the following were reviewed:

Staffing: The facility has sufficient staffing to meet the needs of the residents. There are awake staff providing night supervision.
Personnel Records-Training: LPA reviewed 4 Staff files. The administrator's certificate expires on 1/21/25. Staff have fingerprint clearance and associated to the facility. 2 out of 4 staff files are missing the health screening form. Staff have appropriate dementia care training.
Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and care plan. The physician's report for 3 residents (Residents #1, #2, and #4) are not current.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Residents with SHN: Facility accepts and retain residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. No smoking-Oxygen in use signs are posted where appropriate.

Deficiencies are issued on the LIC809D. An exit interview was held with Cathy Huo. A copy of this report along with appeal rights are given to staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
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)
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Document Has Been Signed on 11/07/2023 06:30 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 11/07/2023 at 05:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually,
Based on record review, the licensee did not comply with the section cited above in which 3 out of 5 residents' physician's report are past a year of its last exam which poses a potential health and safety risk to residents in care.
POC Due Date: 11/21/2023
Plan of Correction
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The administrator shall ensure all residents with dementia have current medical assessments. The physician's report for Residents #1, #2, and #4 shall be submitted to LPA by POC due date 11/21/23.
Type B
Section Cited
CCR
87411(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87411(f) All personnel shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray....not more than six (6) months prior to or seven (7) days after employment or licensure.
Based on record review, the licensee did not comply with the section cited above in which 2 of the 4 staff did not have health screening forms filled out which poses a potential health and safety risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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The administrator shall ensure all staff have health screening completed in their files. The health screening form for Staff #2 and #3 shall be submitted to LPA by 11/21/23.
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 Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
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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