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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005693
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:02:37 AM


Document Has Been Signed on 09/20/2022 11:02 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- NEWPORT MESAFACILITY NUMBER:
306005693
ADMINISTRATOR:MICHAEL MARIONFACILITY TYPE:
740
ADDRESS:350 W BAY STREETTELEPHONE:
(949) 631-2212
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:82CENSUS: 57DATE:
09/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Erin Light - Administrator
Ashley Guerra - Director of Health Services		TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Silverado Senior Living - Newport Mesa. LPA Velazquez was allowed entry into the facility and initially met with Administrative Assistant Yesenia Portillo Avelar. Administrator Erin Light arrived shortly after LPA's arrival as did Director of Health Services (DHS) Ashley Guerra, R.N. The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on September 8, 2022 regarding Resident (R) #1 and R2. A second Incident Report for an incident that occurred on September 6, 2022 involving R2 and R3 was provided to LPA Velazquez at the time of this visit.


On today's visit LPA Velazquez conducted interviews with staff. At 10:40 AM LPA Velazquez along with Administrator Light and DHS Guerra conducted a partial tour of the physical plant and looked in on R1 and R3. There were no immediate health and safety concerns observed with R1 or R3. Per Administrator Light and DHS Guerra R2 is currently hospitalized and not in the community. R2's hospital discharge date has yet to be determined. LPA Velazquez reviewed the files of R1, R2 and R3 and obtained copies of pertinent documentation from their files.


There were no deficiencies issued during this Case Management visit. LPA provided additional consultation regarding the completion of Incident Reports. An exit interview was conducted with Administrator Erin Light and Director of Health Services Ashley Guerra and a copy of this report along with the LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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