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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600026
Report Date: 05/06/2020
Date Signed: 06/16/2020 08:26:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SILVERGATE SAN MARCOS RETIREMENT RESIDENCEFACILITY NUMBER:
374600026
ADMINISTRATOR:JOAN RINK-CARROLLFACILITY TYPE:
740
ADDRESS:1550/1560 SECURITY PLACETELEPHONE:
(760) 744-4484
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:160CENSUS: DATE:
05/06/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Executive Director Joan Rink-CarrollTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Raymond Wu conducted a virtual Case Management visit on this date. LPA met with Executive Director Joan Rink-Carroll and discussed the purpose of the visit.

The visit was in response to the self-reported death of Resident 1 (R1 - See LIC811 Confidential Names List).
Additional information was obtained on this date regarding R1's death.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16), and their authorized representative's signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided to Executive Director Joan Rink-Carroll via electronic mail. An electronic read receipt confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond WuTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2020
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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