198603267-2-24-2025-28-AS-NMAN-DE7VJB-20250224152827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 02/24/2025
Date Signed: 02/24/2025 03:28:45 PM

Document Has Been Signed on 02/24/2025 03:28 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/ DIRECTOR:	GWINN, VIDA		FACILITY TYPE:	740
ADDRESS:	125 E. SIERRA MADRE AVE		TELEPHONE:	(626) 812-9777
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 87	TOTAL ENROLLED CHILDREN: 0	CENSUS: 66	DATE:	02/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Selene Rangel-Gutierez		TIME VISIT/ INSPECTION 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 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. 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).

LPA toured the facility which included the following: common areas, kitchen, dining rooms, activity rooms, living rooms, medication rooms and laundry room. LPA observed cleaning solution, nail polish jar, nail clipper and the duracell batteries in the drawer of the cabinet located in the Terrace Park dining 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. All indoor and outdoor passageways were free of obstruction. The water temperature was tested in a random selection of resident bathrooms in each floor and measured between 110.2F - 116.2F which is within the required 105F - 120F. 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 02/04/25.

Continue 809C

Wei Siew Ho	TELEPHONE: (323) 981-3378
Nune Margaryan	TELEPHONE: 323-981-3378
	DATE: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

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 4

Document Has Been Signed on 02/24/2025 03:28 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: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 solution, nail polish jar, nail clipper and the duracell batteries in the drawer of the cabinet located in the dining room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Cleaning solution, nail polish jar, nail clipper and the duracell batteries were removed and locked immediately.

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.

Wei Siew Ho	TELEPHONE: (323) 981-3378
Nune Margaryan	TELEPHONE: 323-981-3378
	DATE: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

Page: 2 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: 02/24/2025

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
26
27
28
29
30
31
32

Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. LPA observed that there is a sufficient perishable food for 2 days but not enough non-perishable food was observed for 7 days. Cleaning supplies and toxins were observed locked and inaccessible to residents in the laundry room. Multiple First Aid kits were inspected and were fully stocked with current manuals. 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 6 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: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/24/2025 03:28 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: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 that there is not enough non-perishable food for 7 days, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Administrator ordered food at the time of visit and the copy of purchase order was provided.

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.

Wei Siew Ho	TELEPHONE: (323) 981-3378
Nune Margaryan	TELEPHONE: 323-981-3378
	DATE: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4