<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:31:06 PM


Document Has Been Signed on 09/09/2024 12:31 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:VALENCIA, VANESSAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 33DATE:
09/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ashiman Gill, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident reported to our agency on July 29, 2024. LPA was greeted and granted entry into the facility by Ashiman Gill, Administrator (AD) at 10:30am and explained the reason for the visit.

The purpose of today's visit is to follow-up on a self reported incident report received by our Duty Line on July 29, 2024 by Libbie Retts, RN, MSN, CENP, Director of Health Services (DHS). A medication error was reported that Resident #1 (R1) did not receive some medications for three days and medications were discovered by a staff member; who reported to the DHS.

DHS immediately contacted physician and responsible party and investigated the incident with staff. Resident was monitored and did not have any effects from not taking the missing medications. Staff in-service training was conducted to prevent a medication incident from happening again. Corrective action was taken. Two of the four involved with the incident are no longer employed by Silverado.

LPA requested Medication Administration Record (eMAR) for July 2024, in-service training and July staff roster relating to this incident. LPA interviewed AD Gill and DHS Retts. LPA visited R1 and observed resident engaging in activities.

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, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1