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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005692
Report Date: 02/04/2021
Date Signed: 02/04/2021 12:35:41 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 SENIOR LIVING-TUSTIN HACIENDAFACILITY NUMBER:
306005692
ADMINISTRATOR:MUELLER, ADRIENNEFACILITY TYPE:
740
ADDRESS:240 E 3RD STREETTELEPHONE:
(714) 832-7900
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:42CENSUS: 26DATE:
02/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Adrienne Mueller, AdministratorTIME COMPLETED:
12:34 PM
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Licensing Program Analyst (LPA) Jim August conducted an announced Pre-Licensing visit via phone FaceTime virtual technology to Silverado Senior Living-Tustin Hacienda due to the Coronavirus Pandemic and precautionary measures. LPA August conducted the visit with Administrator Adrienne Mueller. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 09/05/2019 for a capacity of 42 non-ambulatory residents with a hospice waiver for 18.

LPA August along with Administrator Mueller toured the facility. LPA toured the physical plant, checked food service, the kitchen, two dining areas, activity room, courtyard and resident rooms. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and showers were free of mold/mildew. Each shower had anti-skid mats. Water temperature measured between 110.3 and 118.4 degrees in resident bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Exit alarms tested operational during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

The facility had a fire drill/inspection last performed on 1/14/2021 and performs quarterly emergency drills such as earthquake or fire emergencies. The last quarterly drill was performed on 11/23/2020. LPA reviewed the liability certificate of insurance and verified the policy is active.

Outside grounds were toured and no bodies of water were observed. Exit gate is unlocked and delayed egress and functions properly.

The Component III Requirement has been waived as the Administrator is currently licensed and in good standing. The facility is ready to be licensed. An exit interview was conducted and a copy of this report will be provided to Administrator Mueller via email. Mueller to sign the report and return to LPA August via email.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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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