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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600026
Report Date: 09/15/2020
Date Signed: 09/15/2020 05:04:02 PM

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: 79DATE:
09/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director Joan Rink-CarrollTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Raymond Wu conducted a virtual Case Management visit on this date. LPA contacted 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. Interviews were conducted and records were requested.

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: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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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