<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005693
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:15:25 PM


Document Has Been Signed on 12/15/2023 02:15 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- NEWPORT MESAFACILITY NUMBER:
306005693
ADMINISTRATOR:HEATHER YOUNANFACILITY TYPE:
740
ADDRESS:350 W BAY STREETTELEPHONE:
(949) 631-2212
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:82CENSUS: 61DATE:
12/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jannette CervantesTIME COMPLETED:
02:30 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
This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 12/08/23 regarding Resident #1 (R1). LPA met with Staff #1 (S1) Jannette Cervantes and discussed the purpose of the inspection. Administrator (AD) Heather Younan appeared via telephone.

The incident report states that on 12/04/23, R1 was given 2 tabs of Tramadol in the evening instead of 1 tab, the error was noticed immediately, R1’s doctor and family were notified, and R1 was observed for any reactions.

During today’s inspection, LPA toured the facility with S1, inspected the medication room, conducted a health and safety check on R1, confirmed R1 was doing well, and observed no health and safety issues. LPA interviewed AD who provided the following information. R1’s doctor advised the facility to monitor R1 closely for 2 hours and that if there was no reaction then no medical treatment would be necessary. R1 was monitored and did not have a reaction and is doing fine.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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


Document Has Been Signed on 12/15/2023 02:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SILVERADO SENIOR LIVING- NEWPORT MESA
FACILITY NUMBER: 306005693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87465(a)(4)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated they will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2