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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608182
Report Date: 12/10/2020
Date Signed: 12/10/2020 04:20:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SILVERADO SENIOR LIVING - BEVERLY PLACEFACILITY NUMBER:
197608182
ADMINISTRATOR:RUSSO, JASONFACILITY TYPE:
740
ADDRESS:330 N HAYWORTH AVETELEPHONE:
(323) 852-9200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:256CENSUS: 99DATE:
12/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Matan BurstynTIME COMPLETED:
04:00 PM
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On 12/10/2020 Licensing Program Analyst (LPA) Kourtney Williams conducted a case management visit telephonically at the above facility in regards to two residents mentioned in an incident report provided by staff Matan Burstyn.


LPA Williams requested copies of residents number one (R1) and residents number two (R2) records to be faxed by 12/11/20. LPA interviewed Burstyn regarding the incident report dated 12/09/20. LPA asked about the status of R1 .



A copy of this report was provided to Matan Burstyn with signature confirming receipt of reports.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Kourtney WilliamsTELEPHONE: (510) 301-5810
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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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