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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603267
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:10:15 PM


Document Has Been Signed on 03/15/2022 02:10 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: 54DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Selene Rangel-GutierrezTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Ms. Rangel toured the facility which included the following: common areas, kitchen, dining room, activity room, living room, and laundry room. A random sample of resident rooms where toured in each wing/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. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bathrooms in each floor and measured between 113F - 117.2F 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/ mildew 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 which were tested and operable during the visit. LPA observed multiple fire extinguishers throughout the facility which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked and are inaccessible to residents. Multiple First Aid kits were inspected and were fully stocked with current manuals. Staff were observed wearing masks and screening visitors at the time of entry.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • 7 resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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