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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:53:10 PM


Document Has Been Signed on 05/22/2023 03:53 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
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: 53DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Director Of Health Care Services Selene Rangel TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Annual Inspection visit focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. LPA met with Selene Rangel (Director Of Health Care Services) and explained the reason for the visit.

The following were observed/inspected: .
Physical Plant: The facility has a fire clearance 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. Outdoor and indoor passageways are free of obstruction. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Rooms observed all furnished as required by title 22 regulations. Bathrooms were clean and operational, water temperature in compliance. Smoke/carbon monoxide detectors were tested and operational. Fire extinguishers observed. Required postings observed. Central Air and Heating with temperature comfortable. Emergency supplies observed. Toxins and sharps locked and inaccessible to residents. 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. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. MEDICATION: Medications are stored, locked and inaccessible to residents. First Aid Kit Observed RECORD REVIEW: Eight (8) Staff Files reviewed. Eight (8) Resident files reviewed. ACTIVITIES: LPA observed activities for resident use as well as sufficient space and accommodations for residents to do activities. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations and Disaster plan is maintained at the facility. Operating telephone was observed and available for resident use.

Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented.

An exit interview was conducted and a copy of today's report was provided and discussed.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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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