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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600026
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:24:23 PM


Document Has Been Signed on 03/29/2024 12:24 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
Lookup Error,
, CA



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: 81DATE:
03/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Joan Rinl-Carroll, DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 03/25/2024 and to clear the plan of correction (POC). LPA identified herself and was granted entry by Edgar Baltazar, Lead Concierge. LPA met with Joan Rink-Carroll, Director, and Ada Navarrete, Director of Resident Care and discussed the purpose of the visit.

During today’s visit, LPA obtained the Director’s signature on the amended report LIC809 dated 03/25/2024 and deficiencies were issued on the attached LIC809-D. The deficiency was deemed cleared during the visit.

An exit interview was conducted with Joan Rink-Carroll, Director, and Ada Navarrete, Director of Resident Care, to whom a copy of this report, the amended deficiency page of the report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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Document is an Amendment of Original Document on 03/29/2024 12:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: SILVERGATE SAN MARCOS RETIREMENT RESIDENCE
FACILITY NUMBER: 374600026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
CCR
87465(g)

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INCIDENTAL MEDICAL & DENTAL CARE - “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…” This requirement is not met as evidenced by:
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The Facility will corrdinate a date of training with their local Fire Department within the next 24 hours and submit a letter to LPA with the date of all staff training to be conducted by 3/26/2024. Facility will submit all staff training documents regarding emergency assessments by 4/16/2024.
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Based on outside source records and interviews, on 04/20/20, the licensee, did not call 911 for 1:79 residents in care until two (2) hours after R1 sustained an unwitnessed fall. R1, who has a history of traumatic injury to the head, sustained an acute subdural hematoma caused by blunt head trauma from a fall which later resulted in death. This poses an immediate health and safety risk to persons in care.
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This is an amended version of the original report created on 03/26/2022.

This POC was cleared while at the facility.

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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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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