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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:20:35 PM

Document Has Been Signed on 10/18/2024 03:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR/
DIRECTOR:		VALENCIA, VANESSAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 70CENSUS: 37DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Tana McMillon, AD and Libbie Retts, RN, MSN, DHSTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge. During today’s visit, LPA met with Tana McMillon, Administrator (AD) and LIbbie Retts, RN, MSN, Director of Health Services (DHS).

The facility is a two story building with an approved fire clearance of seventy non-ambulatory residents of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of thirty-seven residents in care.

At 8:40 AM LPA toured the facility and spoke with residents in the dining room after breakfast. Staff members were escorting residents to the common areas and to convert the dining room for residents to have a scheduled fitness activity at 9:30 AM. LPA noted the activity would be a zumba class.

LPA inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on the delayed egress exits in the Birch neighborhood. The hot water temperature measured between 107.0 and 109.4 degrees Fahrenheit and all smoke detectors were operational and were recently tested by Smart Systems Technologies on October 17, 2024. Fire extinguishers throughout the community were charged and serviced on April 2, 2024. The facility’s last fire drill was conducted on October 3, 2024 by Fire Safety Services, Inc.and are done quarterly. LPA observed one of two elevators were out-of-order but Otis Elevators has conducted an inspection and parts are currently being ordered to repair elevator.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SILVERADO BREA LLC
FACILITY NUMBER: 306005652
VISIT DATE: 10/18/2024
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(Continued from LIC 809)

LPA inspected the facility food supply with the Director of Culinary Services and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Dietary modifications are in a binder in the kitchen. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA reviewed five of five staff training and fingerprint records and five of five resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 10, 2025.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Administrator and Libbie Retts, RN, MSN, Director of Health Services and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
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