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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:43:46 PM

Document Has Been Signed on 01/16/2025 04:43 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:		TANA MCMILLONFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 70CENSUS: 40DATE:
01/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Ashiman Gill, Executive Director (ED)TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert attempted an unannounced visit on January 15, 2025 at 4:10pm to conduct a Case Management visit. The Regional Office received an Unusual Incident Report on January 10, 2025 regarding a resident elopement. During today's visit the Executive Director (ED) was at a sister community and the Director of Health Services (DHS) was on a scheduled phone call for a family meeting. LPA will return to conduct the Case Management visit at a later date.

LPA returned on this date to conduct the Case Management visit. LPA was greeted and granted entry by the receptionist and met with Executive Director (ED), Ashiman Gill. LPA explained the purpose of the visit and requested the following documents: Staffing schedule for Thursday, January 9, 2025, Resident Emergency and Identification Form, Physician's Report and Appraisal. LPA also obtained staff Elopement Drill In-service documents and nurses notes.

ED Gill showed LPA the courtyard exit that led to the resident elopement. Resident exited the courtyard door and was visually sighted by the front desk receptionist. Within minutes the Office Service Manager (OSM) and Director of Residents and Engagements (DRE) were with resident and DRE redirected resident back into the community, with assistance from other staff members. The OSM and ED initiated the community's elopement procedures and all staff checked exit doors and did a resident head count to make sure all were secured. Responsible party was notified and the resident was assessed

ED provided an Elopement Drill In-service to all staff and it was determined an associate had not completely closed the exit door; while taking out trash and was given associate counseling. The courtyard exit door will now remain locked, with management doing checks daily to make sure the door is closed. Staff were told not to use the courtyard exit to perform job duties and a loud audible alarm was installed on the door, to alert staff if the door is open, the very next day. (Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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: 01/16/2025
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(Continued from LIC 809)

LPA observed resident participating in group chair exercise and enjoying the workout. Afterwards LPA spoke with resident, who stated, "I'm fine. Everything is okay." LPA thanked the resident for the interview.

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 Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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