306005692-8-23-2024-22-AS-RMRT-D8EU9E-20240823152300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005692
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:24:28 PM

Document Has Been Signed on 08/23/2024 03:24 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-TUSTIN HACIENDA		FACILITY NUMBER:	306005692
ADMINISTRATOR:	ERIN LIGHT		FACILITY TYPE:	740
ADDRESS:	240 E 3RD STREET		TELEPHONE:	(714) 832-7900
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	42	CENSUS: 29	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Sheila Fike, Administrator		TIME COMPLETED:	03:30 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 made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #6 at 8:00 AM. During today’s visit, LPA met with Sheila Fike, Administrator (AD) and Benjamin Velasquez, Administrator-in-Training (AIT). The facility is a single story building with an approved fire clearance of forty-two non-ambulatory residents of which eighteen may be on hospice. The facility currently has a census of twenty-nine residents in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in five of five resident bathrooms, and testing auditory delayed egress devices on all exits. The hot water temperature measured between 110.6 and 117.8 degrees Fahrenheit and all smoke detectors and carbon monoxide detectors were operational. The fire extinguishers are charged and were serviced on March 25, 2024. The facility’s last fire drill was conducted on July 11, 2024. The PUB 475 poster was observed to be the incorrect size. Facility immediately ordered the required 20" X 26" and provided proof of documentation. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed five of five staff training and fingerprint records. LPA reviewed five of five resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 17, 2025. (see LIC 809-C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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 2

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-TUSTIN HACIENDA	FACILITY NUMBER: 306005692
	VISIT DATE: 08/23/2024

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
26
27
28
29
30
31
32

(Continued from LIC 809)

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 Sheila Fike, AD and Benjamin Velasquez, AIT and a copy of the report, Technical Assistance (LIC 9102-TA) and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2