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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005692
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:33:15 AM


Document Has Been Signed on 04/28/2022 11:33 AM - It Cannot Be Edited

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:ERIN LIGHTFACILITY TYPE:
740
ADDRESS:240 E 3RD STREETTELEPHONE:
(714) 832-7900
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:42CENSUS: 26DATE:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Dwight Dunagan - Adminstrator and Ashley Guerra - Director of Health TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 04/19/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Dwight Dunagan, Administrator and Ashley Guerra RN, Director of Health Services.

Incident report indicated Resident 1 (R1) had an un-witnessed fall on 04/15/2022. At 12:00pm R1 was found on the floor by LVN Melinda Smith. Nursing was notified and assessment was conducted. R1 had pain above the knee. X-ray was performed in house and results were shared with R1 physician and family. R1 family elected to have R1 placed on hospice care. Hospice visits twice a week and as needed.

During the visit LPA reviewed LIC 602, Hospice admission form and staff list from 4/15/2022.






No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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