374604254-3-3-2021-08-AS-DCOA-BYRTVF-20210303140353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604254
Report Date: 03/02/2021
Date Signed: 03/03/2021 02:04:20 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:	SILVERADO SENIOR LIVING-ENCINITAS		FACILITY NUMBER:	374604254
ADMINISTRATOR:	JOHNSON, MARIVEL		FACILITY TYPE:	740
ADDRESS:	335 SAXONY ROAD		TELEPHONE:	(949) 240-7200
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	122	CENSUS: 80	DATE:	03/02/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Applicant, Marivel Johnson		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Debbie Correia, conducted an announced Pre-licensing and Component III virtual visit to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. The visit was conducted via FaceTime due to COVID-19. LPA Correia identified herself to Applicant, Marivel Johnson, and explained the purpose of the virtual visit. Application is to serve 122 elderly residents, ages 60 and above, all (122) of whom may be non-ambulatory and 25 of whom can be receiving hospice services. The Encinitas Fire Clearance on October 29, 2019. During today's visit, LPA Correia, accompanied by Applicant, Marivel Johnson, conducted a virtual tour of the facility. According to Marivel Johnson, there will be no firearms or ammunition stored on site. LPA Correia observed a pool on the premises that is used for group activities, the pool is properly secured with a fence and a locked gate to enter from the outside area, the facility doors that give lead to the pool area are all equipped with keypad locks that require a combination for access. The facility also contracts with the agency Johnson Controls who provides maintenance on the to ensure the keypad locking mechanism at the pool doors, and delayed egress, signal systems, and fire alarm system are all operational. The agency Ciscor is also utilized to conduct inspections on the lighting signal system. Outdoor and indoor passageways are free from obstructions. All window screens are clean and in good repair. Hall-way lights remain on at all times. Fire Extinguisher (expires,12/2021), smoke alarms, and carbon monoxide detectors, were observed and operational, throughout the facility. Facility has a locked laundry room and maintains sufficient supplies of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, towels, and washcloths. On-site maintenance is present to fix any issues in a timely manner.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS	FACILITY NUMBER: 374604254
	VISIT DATE: 03/02/2021

NARRATIVE

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Resident rooms were well kempt with all required furniture, bedding and closet space. Resident bathrooms are also in good repair, equipped with handrails, non-skid shower flooring, soap and paper towels, sufficient hygiene products for personal use, as needed. Facility kitchen maintains locked and inaccessible to residents in care. LPA Observed a sufficient supply of clean utensils and equipment for proper storage of food items. A seven day amount of non-perishable food and two day amount of perishable food were observed. Freezer temperature measured at -10 degrees and the refrigerator measured at 38 degrees. There is confidential storage area for personnel and resident records. Resident and staff records were present and up to date. Facility utilizes the e-mar, and distributes medication kept in self- locked medication carts.

There is a locked storage area for toxic chemicals. Resident and staff records, and documentation of medication management are complete and maintained on the premises. Emergency exit plans, infectious disease awareness, facility policy, and residents' personal rights are posted in prominent areas. There is a shaded outdoor space, a common room available for visitors, and activity supplies, for use when appropriate.

LPA observed first aid kits and manuals at the facility, the facility has 24 hours nurses. Facility has a laundry area with sufficient space and cleaning supplies available for laundry. There is an operating telephone line. Hot water temperature measured 109.4 to 113.9 throughout facility bathrooms, and the facility temperature was set at 73 degrees F. Applicant Marivel Johnson administrative certificate is in a pending status, all requirements were completed and turned in prior to expiring in 1/2021.

Component III was completed with the facility representative via FaceTime. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review, pre-licensing is complete.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Applicant, Marivel Johnson via e-mail address. An electronic e-mail read receipt confirms delivery of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

LIC809 (FAS) - (06/04)

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