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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:29:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:KAUTEN, MARIAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 29DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Judy Franco, Director of Health ServicesTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit. LPA's temperature was taken upon arrival.

During the visit LPA toured the facility with Director of Health Services Judy Franco. Facility is a two story 40 bedrooms ( 7 private rooms and 33 companion rooms) Memory Care Building. There are 29 Residents in care. LPA observed proper covid signage at front entrance of facility as well as a sign in and temperature check station. Facility has required Department postings. LPA toured Residents rooms, rooms where within regulations. All restrooms observed contained soap, toilet paper, and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in Living room areas watching TV. Facility has has 10 fire extinguishers which are fully charged and mounted on walls of community. Facility has ample supply of PPE. Facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted on wall. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Director of Health Services and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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