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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005691
Report Date: 02/24/2021
Date Signed: 02/26/2021 11:40:52 AM

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 SENIOR LIVING-SAN JUAN CAPISTRANOFACILITY NUMBER:
306005691
ADMINISTRATOR:LIGHT, ERINFACILITY TYPE:
740
ADDRESS:30311 CAMINO CAPISTRANOTELEPHONE:
(949) 240-0550
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:96CENSUS: 65DATE:
02/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Erin LightTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Joseph Alejandre contacted Administrator Erin Light via iPhone to conduct the prelicensing inspection via FaceTime due to Covid-19 precautionary measures. The facility is currently operating under license number 306004350. The Licensee Corporation is changing. Facility will retain the same name Silverado Senior Living-San Juan Capistrano with a new Licensee and new License number 306005691. The new facility will be licensed as an RCFE with a capacity of 96. Facility will provide Dementia care. The Fire Clearance has been approved by San Juan Capistrano Fire Department Fire Inspector Ruben Gomez, on 12/19/2019. The application was received by CCL on 8/26/2020. Facility phone number is 949-240-0550. LPA Alejandre toured the facility via FaceTime with Administrator Erin Light. Structure; Facility is one story with 48 resident rooms, and a center courtyard area for residents. Bedrooms Residents. All resident rooms have their own bathroom. LPA observed that rooms had a night stands, lamps and chairs and enough closed space to accommodate resident's belongings. Bathrooms. were clean, faucets and toilets were operational, grab bars secure and showers had slip mats. Water temperature measured 114 degrees Fahrenheit. Linens & Hygiene Supplies. Linen closet was well stocked with linens and towels. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. seven days nonperishable food supply and two day perishable food supply reviewed. LPA inspected the Kitchen and Dining room. Both were clean and free of hazards. Carbon Monoxide, Smoke Detectors, Fire Extinguishers were observed. All monitors tested during fire clearance inspection and are operational. Toxins: cleaning supplies were kept locked in a storage closet and is inaccessible to residents. Medication room is kept locked and inaccessible to residents. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files No files reviewed. LPA observed an outdoor patio area with seating for residents. No bodies of water observed. LPA observed all staff were wearing masks and residents were social distanced. LPA observed Covid-19 sign/precautions throughout the facility. LPA observed the front desk area had a check in area with a station to screen visitors for temperature and symptoms. LPA observed that the facility had a 30 day supply of PPE. LPA Alejandre conducted component III presentation with the Administrator Light.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SILVERADO SENIOR LIVING-SAN JUAN CAPISTRANO
FACILITY NUMBER: 306005691
VISIT DATE: 02/24/2021
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During the visit LPA Alejandre explained the process of this application and also about the post licensing visit once the facility is licensed. Administrator was informed that the facility meets Title 22 Division 6 of the California Code of Regulations. Facility is now ready for licensure.

Administrator was informed today that the final approval will be processed by the CAB specialist in Sacramento.

An exit interview was conducted and a copy of this report, LIC809 was explained and provided to Administrator Erin Light via email, electronic read receipt confirms Administrator receiving the report
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
LIC809 (FAS) - (06/04)
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