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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604254
Report Date: 05/07/2024
Date Signed: 05/07/2024 03:52:07 PM


Document Has Been Signed on 05/07/2024 03:52 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SILVERADO SENIOR LIVING-ENCINITASFACILITY NUMBER:
374604254
ADMINISTRATOR:JOHNSON, MARIVELFACILITY TYPE:
740
ADDRESS:335 SAXONY ROADTELEPHONE:
(949) 240-7200
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:122CENSUS: 76DATE:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marivel Johnson, Executive DirectorTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management investigation. LPA Lopez identified herself and was granted entry by concierge Caroline Fitzgerald. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson.

This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on Monday, May 6, 2024. The IR said that there was an incident that had transpired on Tuesday, April 30, 2024, with resident #1 (R1) who sustained injuries.

During today's visit LPA Lopez spoke with staff and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified the facility staff who found resident and made contact with their nurses. The facility staff who arrived at the scene contacted the nurse who then called paramedics who transported the resident to the hospital where resident was seen. LPA informed Executive Director Marivel Johnson that there may be further follow-up telephone calls or visits for this incident. LPA requested for Executive Director Johnson to submit a death certificate upon receipt to LPA Lopez.

An exit interview was conducted with Executive Director Marivel Johnson, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to ED Johnson at the conclusion of the visit. The signature below confirms that the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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