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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600907
Report Date: 02/23/2023
Date Signed: 02/23/2023 12:15:53 PM


Document Has Been Signed on 02/23/2023 12:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 114DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:ADMINISTRATOR, PATRICIA MARTINEZ.TIME COMPLETED:
12:28 PM
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On February 23, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control.

LPA Mixson was greeted and granted entry by Receptionist introduced self, had temperature taken at the kiosk, and signed in. LPA Mixson later spoke with Administrator introduced self and stated the purpose of the visit.

Present in the facility were 114 residents and 95 caregivers and other staff. There are currently no positive cases of COVID-19 within the facility. All staff and all residents are vaccinated and have received boosters.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

Additionally, the facility has a plan in place to monitor resident's regularly for any changes in condition and to subsequently notify the resident's physician, and/or to notify all emergency agencies in the event of any COVID-19 related, or suspected illnesses.
LPA Mixson later discussed infection control practices and procedures with Business Office Manager.
An exit interview was conducted and a copy of this report was given to Business Office Manager.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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