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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:42:04 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SILVERADO SENIOR LIVING-SIERRA VISTAFACILITY NUMBER:
198603267
ADMINISTRATOR:GWINN, VIDAFACILITY TYPE:
740
ADDRESS:125 E. SIERRA MADRE AVETELEPHONE:
(949) 240-7200
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:87CENSUS: 54DATE:
07/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Selene RangelTIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPAs) David Sicairos and Luis Mora conducted an unannounced case management visit in regards to a Special Incident Report that was submitted to Licensing on 06/21/21. LPAs met with Selene Rangel and explained the reason for the visit.

Per Incident Report on 06/17/21, Staff #1 (S1) - Staff #2 (S2) noted that the medication in the medication card did not match the stated medication on the label. Upon further assessment it was noted that various medication cards had been tampered with. Cards appeared to have been cut and taped, visible only when held against the light. Azusa Police Department was called and an investigation was opened. On 06/30/21, Detective informed Administrator and Director of Care Health Services that there are two persons of interest (Staff #3 - Staff #4). Both employees have been suspended from facility pending investigation. Door codes and locks on medication carts have been changed and police investigation is still ongoing. LPA advised Administrator and Director of Health Care Services to keep Licensing informed of the police investigation findings. LPA also requested copy of the Police Report when it becomes available.


No deficiencies were cited during today's visit. Exit interview held and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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