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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:59:29 PM


Document Has Been Signed on 10/19/2022 01:59 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:VALENCIA, VANESSAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 34DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Specialist Gigi McCorkleTIME COMPLETED:
02:20 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.

LPA Tirre met with Administrator Specialist Gigi McCorkle. LPA toured the facility's Physical Plant. Facility is a two story 40 bedrooms ( 7 private rooms and 33 companion rooms) Memory Care Building. There are 34 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. Facility has Emergency Disaster Plan and Evacuation Plan posted. LPA toured Residents rooms, all rooms observed 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 common areas watching TV and eating lunch in dining rooms. LPA observed 9 fire extinguishers which are fully charged and mounted on walls of community. Facility has operating Smoke Detectors which passed inspection by Control Fire & Security dated on 6/28/22. Documentation for Smoke Detectors was provided.

LPA Observed kitchen area Refrigerators and pantry. Facility has ample food supply. Facility has Ample Emergency food and water supply. Facility has ample supply of PPE. 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. LPA reviewed Seven Resident files. Residents emergency contact information is current. Facility has several designated visitation areas. Facility Staff were all observed following proper Covid 19 protocol wearing Face masks.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Specialist 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: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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