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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603266
Report Date: 04/06/2021
Date Signed: 04/08/2021 03:22:04 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:
198603266
ADMINISTRATOR:BELSON, MYLAFACILITY TYPE:
740
ADDRESS:330 N. HAYWORTH AVETELEPHONE:
(949) 240-7200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:256CENSUS: 99DATE:
04/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Myla Belson, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Ana Soto, conducted a announced visit to the facility for the purpose of a Pre-Licensing evaluation. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted a tele-visit with Myla Belson, the facility administrator.

An application was submitted to Community Care Licensing Department (CCLD) on 03/16/2021 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (256) Residents,(0) ambulatory, (164) non-ambulatory, and (92) bedridden. Structure: Facility is a yellow stucco building. The facility has 3 floors, 114 rooms, and 2 elevator. The First floor it has a lobby, receptionist counter, family visit room, kitchen, dining room, house keeping closet, TV room, common areas, and medication room . They have the required Covid-19 posting on the front door, along with the sign-in log sheet and sanitary station. They have the residents rooms are also on the 1st Floor, Patio has( 2 tables, 2 umbrellas, and 2/3 chairs.) The 2nd and 3rd floors are the same the design as the first floor, except that on the 2nd floor they have a computer station for residents, Room 250 used for storage for the facility and Room 252 is used for supplies for the nurses. Room 224 is used for PPE storage. The 3rd floor has a beauty salon. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night stands, two lamps and overhead lighting. Presently, the 1st & 2nd Floors bedrooms are occupied by 2 clients. The 3rd floor are 1 resident private rooms. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 124 bathrooms, 60 114 located in each room of the 3 floors of the facility: have working toilets and wash basin, a walk-in shower with folding bench, grab bars, and mats. 12 other bathrooms are visitor bathrooms, located in every floor. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in garage where the Laundry room is located.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PLACE
FACILITY NUMBER: 198603266
VISIT DATE: 04/06/2021
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. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in lobby. Facility has a land line telephone located in the receptionist station/ Lobby. 3 Fire extinguisher, in the kitchen areas of the 3 floors, which are labeled, they are tagged with current annual checks. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 118 hard wired and inter-connected smoke detectors which are connected to the Fire Department . Carbon monoxide detectors in all the rooms in the facility. Appliances: Stove burners, oven, microwave, freezers and washers/dryers are in working condition. The residence is equipped with central heat and air conditioning. There is thermostat's for each floor to regulate the temperature in the residents rooms. Toxins: Cleaning supplies, and toxins are stored in the laundry room in the basement. Water Temperature: Water was tested in bathrooms and kitchen sink within 105-120 degrees Fahrenheit range. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located the 1st, 2nd, and 3rd floors in the wellness rooms. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which are stored with medication in the wellness rooms, available for staff use but inaccessible to clients. Clients & Staff Files: Designated area for files will be located in the administrators office. Pools/Jacuzzi & Pets: No bodies of water on these premises. The facility has 10 pets (dogs) in the facility. Fire Clearance: Fire clearance does indicate delayed egress or any locked perimeter. Component III was waived, due to facility already manages other facilities presently. LPA also explained ROM 20-28 at the time of the Pre-Licensing.

There are no corrections to be made.



A tele-visit exit interview was conducted and a copy of this report has been furnished to the applicant via email for signature. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC809 (FAS) - (06/04)
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