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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005691
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:49:15 PM


Document Has Been Signed on 03/12/2024 05:49 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 SENIOR LIVING-SAN JUAN CAPISTRANOFACILITY NUMBER:
306005691
ADMINISTRATOR:SHEILA FIKEFACILITY TYPE:
740
ADDRESS:30311 CAMINO CAPISTRANOTELEPHONE:
(949) 240-0550
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:96CENSUS: 64DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sheila FikeTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (ED) Sheila Fike and explained the reason for the visit. Sheila Fike's Administrator's certificate expires 7/17/2025. LPA and ED toured the facility. Facility is a single story building with 44 resident rooms. LPA and ED toured 7 resident rooms. LPA observed the see something say something poster (PUB 475) is only 14 X 22 inches. LPA observed all resident rooms had the required furnishings. Each room had it's own carbon monoxide detector, all tested operational. Hot water measured from 116.6 degrees Fahrenheit to 121.0 degrees Fahrenheit. LPA observed the bathrooms were clean and operational. During the visit LPA observed the Director of Plant Operations setting the hot water temperature to 120.0 degrees Fahrenheit. LPA observed all hallways were free of obstruction. LPA and ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. LPA observed all the refrigerators and freezers had temperature logs. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed an emergency food and water supply on hand in the kitchen. LPA and the ED toured the courtyard of the facility. There is a raised fountain in the courtyard. There are seating areas with tables and chairs in the courtyard with umbrellas for shade. No obstacles or hazards observed outside of the facility. LPA observed all fire extinguishers in the facility are fully charged. LPA observed all medication is kept locked in medication carts which are stored in the medication room. LPA observed the first aid kit in the medication room has all the required elements. LPA reviewed 6 resident files and medications. No discrepancies observed. LPA reviewed 6 staff files. LPA observed 1 out of 6 staff members did not have the required 20 hours of annual training. Based on the observations made during today’s visit deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

An exit interview was conducted and a copy of the report ( LIC 809) provided along with citations (LIC 809D) and appeal rights was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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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Document Has Been Signed on 03/12/2024 05:49 PM - It Cannot Be Edited

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 SENIOR LIVING-SAN JUAN CAPISTRANO
FACILITY NUMBER: 306005691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 6 staff members meeting the 20 hours of annual training required which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee agrees to train Staff 6 (Staff member who did not have 20 hours of training) to meet the 20 hours of training by 4/1/2024. Licensee agrees to ensure all staff meet al the requirements of HSC 1569.625. LPA to be provided proof of training by 4/1/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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