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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600026
Report Date: 03/05/2021
Date Signed: 04/01/2021 01:50:14 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: 91DATE:
03/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:44 PM
MET WITH:Joan Rink-CarrollTIME COMPLETED:
04:27 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA identified herself and stated the purpose of the visit to Executive Director Joan Rink-Carroll. LVN Diane Wheeler was also present.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on March 02, 2021. The facility reported that on February 21, 2021, R1 left the facility (AWOL) and was returned to the facility by staff. The facility also reported that on February 22, 2021 the resident again left the facility. Staff were able to once again redirect the resident back to the community.

On today’s date, LPA toured the facility and conducted a health and safety check. LPA briefly interviewed the Executive Director and LVN Diane Wheeler, and requested copies of additional facility records. No deficiencies were cited at this time.

An exit interview was conducted with the Executive Director Joan Rink-Carroll, to whom a copy of this report, LIC811 Confidential Names list, and the LIC9058 Licensee/Appeal Rights were provided via E-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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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