198603267-3-5-2021-28-AS-DSIS-BYTSXR-20210305131623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 03/04/2021
Date Signed: 03/05/2021 01:16:41 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SILVERADO SENIOR LIVING-SIERRA VISTA		FACILITY NUMBER:	198603267
ADMINISTRATOR:	GWINN, VIDA		FACILITY TYPE:	740
ADDRESS:	125 E. SIERRA MADRE AVE		TELEPHONE:	(949) 240-7200
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	87	CENSUS: 50	DATE:	03/04/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Vida Gwinn & Selene Rangel		TIME COMPLETED:	03:30 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	Licensing Program Analyst (LPA) David Sicairos conducted an announced pre licensing visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Microsoft Teams with Administrator Vida Gwinn & Selene Rangel Director of Health Care Services. The facility has a fire clearance from the local Fire Department approved for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 12 residents. Approved for delayed egress, secured perimeter, and secured locked perimeter. This is a 2 story building which includes Terrace Park (1st floor and 2nd floor) and Canyon View (1st floor). The following areas were inspected during the televisit tour of the physical plant with the Administrator: Common areas, kitchen, dining room, activity room, living room, and laundry room. A random sample of resident rooms were inspected in each floor. Resident bedrooms have the required furniture with sufficient closet space. Bathrooms were clean, toilets and water faucets worked properly and included all functional fixtures such as secure grab bars. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold/ mildew and non-skid mats or strips were properly in place. Water temperature was measured in various different resident bathrooms throughout the facility and measured between 105.2F - 118.5F which meets Title 22 Regulations. A locked storage area for central storage of medications were observed in both medication rooms. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. Several fire extinguishers were observed throughout the facility in the hallways. Smoke detectors and carbon monoxide detectors were observed throughout the facility which are hardwired and operable in the common areas. Each resident bedroom also has carbon monoxide detectors. Doors, exits, hallways, and passageways were clear and free of obstruction. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. (CONTINUED ON 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING-SIERRA VISTA	FACILITY NUMBER: 198603267
	VISIT DATE: 03/04/2021

NARRATIVE

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All necessary postings were observed to be posted in appropriate places. A current disaster and mass casualty plan is maintained at the facility. An operating telephone was observed on the premises, which is easily accessible and available for resident use.

Several first aid kits were observed throughout the facility which included all required supplies. The refrigerators were observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwaves, refrigerators, and stoves were observed to be clean and operating properly. Food utensils were clean and sufficient for the number of residents to be served. The outdoor patio areas were observed to have well shaded areas and were furnished for outdoor use.

No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA Sicairos will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was emailed to the Administrator and Director of Health Care Services for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC809 (FAS) - (06/04)

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