198320131-5-31-2024-11-AS-WGIS-D5SVPR-20240531163711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320131
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:37:21 PM

Document Has Been Signed on 05/31/2024 04:37 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SILVERADO ROLLING HILLS		FACILITY NUMBER:	198320131
ADMINISTRATOR:	LOURDES MENCHACA		FACILITY TYPE:	740
ADDRESS:	2455 PACIFIC COAST HWY		TELEPHONE:	(424) 488-0593
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	68	CENSUS: 45	DATE:	05/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:			TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/31/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted and unannounced annual visit. LPA met with Training Administrator, Farid Taheri, and the purpose of today’s visit was explained. The facility is licensed to serve (68) of which (60) are non-ambulatory and (68) bedridden elderly adults ages 60 and above. The facility is approved for (10) hospice residents. Currently, the facility has ten (10) residents on hospice care. Physical Plant/Structure The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (47) resident bedrooms. Each room has a bathroom in the unit. There are administrative offices, a copy room, an activity area, dining areas, a kitchen, a beauty shop, medication rooms, and an outside patio. LPA observed all walkways around the building to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected seven (7) resident rooms, including 101, 104, 107, 108, 203, 207, and 227, and observed them to be clean and in good repair. LPA observed all rooms to be properly furnished with a bed, dresser, nightstand, chair, and storage space for resident’s personal belongings. Residents have the option to furnish rooms with

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 05/31/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

their personal furniture or the facility has furniture available for them. LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed some residents have their personal linens stored in their rooms and the facility has an ample supply in a storage room for resident use. All rooms were observed with ample lighting.
Bathrooms LPA inspected seven (7) resident bathrooms and observed them to be clean, operational, and meet Tittle 22 regulations. LPA observed storage area for residents’ personal hygiene products. The facility does have an ample supply of hygiene products available for residents. The water temperature in the resident’s bathrooms measured between 111.4-degrees and 116.7-degrees Fahrenheit.
Common Rooms LPA inspected all common rooms in the facility and observed them to be properly furnished to accommodate all residents. LPA observed all walkway and hallway in the facility to be clean, clear, and free of obstructions and hazards. LPA observed all common areas to have ample lighting. The facility was kept at a comfortable temperature. LPA observed resident’s participating in activities.
Kitchen LPA inspected the facilities industrial kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored, packaged, and labeled.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 05/31/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medications LPA observed all centrally stored medications secured in a locked med cart in the locked medication room and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the electronic Medication Administration Record (eMAR) for five (5) residents. LPA observed five (5) out of five (5) resident’s eMARs and medication are consistent with properly documented records.
File Review/Interviews LPA reviewed five (5) resident files and found they had the required documents. LPA interviewed five (5) resident and all residents are happy with the care and treatment they receive at the facility. LPA reviewed five (5) staff file and the Administrator file and observed they had the required documents, training, and certifications. LPA interviewed five (5) staff and they were able to answer questions regarding policy, procedure, resident care, and resident personal rights.
Safety LPA observed multiple fully charged fire extinguishers throughout the facility last serviced on 04/16/24. The last inspection from Fire Alarm and Life Safety System was conducted on 02/28/24. The last emergency drill was conducted on 05/17/24. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. The elevator was last inspected and serviced on 03/13/24. LPA received and reviewed a copy of the facility’s Liability Insurance. LPA inspected the generator and reviewed the logs; it was last serviced on 04/30/24 and is started and ran weekly. LPA observed all cleaning supplies secured in the locked housekeeping cart and in a locked storage room. All sharps are secured and inaccessible to residents.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 05/31/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Infection Control LPA observed required infection control signs posted throughout the facility. LPA observed sanitizing stations throughout the facility. LPA observed an ample supply of cleaning supplies. The facility has a 60-day supply of Personal Protective Equipment (PPE). LPA reviewed the facility visitor log with temperatures.

During today’s visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Training Administrator, Farid Taheri, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4