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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608182
Report Date: 05/25/2021
Date Signed: 05/26/2021 06:37:21 AM

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
MONTERY 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:0CENSUS: 105DATE:
05/25/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jason Russo & Myla BelsonTIME COMPLETED:
10:35 AM
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On 05/25/21 at 10:`15 am Licensing Program Analyst(s) (LPA) Ernand Dabuet and (LPA) Don Senaha initiated a Case Management visit at this facility. LPAs met with Jason Russo Regional Administrator and Myla Belson, Administrator. LPAs explained the purpose of this visit is to return Resident #1 (R1)’s service file records at this facility.

These records are information associated with complaint control number 11-AS-20200529144134.

An exit interview was conducted with Jason Russo and Myla Belson, and a hard copy was provided via email.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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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