198603267-3-12-2024-28-AS-NMAN-D3B2KH-20240312172759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:28:06 PM

Document Has Been Signed on 03/12/2024 05:28 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 VISTA		FACILITY NUMBER:	198603267
ADMINISTRATOR:	GWINN, VIDA		FACILITY TYPE:	740
ADDRESS:	125 E. SIERRA MADRE AVE		TELEPHONE:	(626) 812-9777
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	87	CENSUS: 64	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Selene Rangel-Gutierez		TIME COMPLETED:	05:20 PM

NARRATIVE

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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez who assisted with visit. PA explained the reason for the visit. The facility is licensed for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 25 residents. Currently 6 residents on hospice. This is a 2-story building which includes Terrace Park (1st floor and 2nd floor) and Canyon View (1st floor).

LPA toured the facility which included the following: common areas, kitchen, dining rooms, activity rooms, living rooms, medication rooms and laundry room. Required postings were observed. A random sample of resident rooms where toured in each building / floor. There are multiple shaded areas available for resident use. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. During the tour LPA observed wood pallets, old / broken commodes, old / broken commercial sink, broken grill, broken old furniture in the back of facility, and in the front of laundry room. The water temperature was tested in a random selection of resident bathrooms in each floor. Water temperature was tested in the bathrooms in the rooms # 17, # 15, and # 14 and the reading shows 120.3 degree F, 122.5 degree F and 66.7 degree F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold and non-skid mats or strips were properly in place. Smoke detectors and carbon monoxide detectors were observed throughout the facility and in each resident room. Several fire extinguishers were observed throughout the facility in the hallways. Last Fire drills were conducted on 02/12/24 and 02/15/24.

Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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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Document Has Been Signed on 03/12/2024 05:28 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Water temperature was tested in the bathrooms in the rooms # 17, # 15, and # 14 and reading was shows 120.3 degree F, 122.5 degree F and 66.7 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Water temperature was adjusted at the time of visit.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed cleaning supplies and toxins in the Laundry Room unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Laundry room door was locked immediately.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/12/2024 05:28 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. At the time of visit LPA observed wood palets, old / broken commodes, old / broken commercial sink, broken grill, broken old furniture in the back of facility, and in the front of laundry room, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	The licensee / Administrator will ensure passageway in the left side of facility and in the front of laundry room are maintain clean of debris and obstructions and submit a picture by 3/25/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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
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: 03/12/2024

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Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed. Cleaning supplies and toxins were observed unlocked and accessible to residents in the laundry room. Multiple First Aid kits were inspected and were fully stocked with current manuals. 6 resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed. LPA reviewed 3 resident records and 4 staff records.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Selene Rangel-Gutierez.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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