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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005692
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:05:10 PM


Document Has Been Signed on 09/22/2022 03:05 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
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: 32DATE:
09/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Malinda Smith - Charge Nurse, Erin Light - Senior Administrator TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 09/20/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Charge Nurse Malinda Smith. Senior Administrator Erin Light arrived at 2:30 PM

Incident report indicated Resident 1 (R1) had an altercation with Resident 2 (R2)

Per interview with staff 1 (S1) S1 stated R1 approached R2 and another resident at 7:30 am on 09/18/2022. R1 reached for the side of R2's neck ,R2 then grabbed R1's hand and pinched R1. R1 then hit R2 on the forehead with an open hand. R2 then hit R1 3 times on R1's chest with a closed fist. R1 then tried to walk around R2 and reached for R2's neck area where it meets the shoulder. R1 was redirected and both residents were assessed. No injuries notated for either resident. R1 was given 1:1 caregiver until a bed was available at behavioral health hospital. R2 was taken to hospital for psych evaluation. Both are currently at the hospital. R1 and R2's responsible parties and physicians were notified.

Both R1 and R2 are diagnosed with dementia based on LIC 602 dated 05/27/22 for R1 and 05/17/22 for R2.

During the visit, LPA reviewed LIC 602, incident report and services plans for both R1 and R2.

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: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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