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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600907
Report Date: 02/10/2022
Date Signed: 02/10/2022 02:21:43 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 FALLBROOK RETIREMENT RESIDENCEFACILITY NUMBER:
374600907
ADMINISTRATOR:PATRICIA A MARTINEZFACILITY TYPE:
740
ADDRESS:420 ELBROOK DRIVETELEPHONE:
(760) 728-8880
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:145CENSUS: 117DATE:
02/10/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Patricia Martinez, AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst, Kristina Ryan, and County of San Diego Nurse HAI Site Assessment Contractor, Robert Montillano conducted an announced on-site visit. The team identified themselves and discussed the purpose of the visit with Administrator, Patricia Martinez.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Ms, Martinez and conducted a walk-through of the facility. A debriefing was conducted with Ms. Martinez at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Ms, Martinez and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the administrator via electronic mail. An electronic receipt confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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