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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604323
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:27:01 PM


Document Has Been Signed on 01/12/2023 02:27 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SILVERGATE RANCHO BERNARDOFACILITY NUMBER:
374604323
ADMINISTRATOR:BRAKEVILLE, SONDRAFACILITY TYPE:
740
ADDRESS:16061 AVENIDA VENUSTOTELEPHONE:
(858) 451-1100
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:285CENSUS: 217DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Sondra Brakeville, Administrator/EDTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management visit. LPA was allowed entry by the receptionist. LPA identified herself, disclosed the purpose of the visit, and met with Sondra Brakeville, Administrator/Executive Director. .

Today's visit is in response to the self-reported incident which happened on 11/01/2022 regarding Resident 1 (R1 - See LIC811 Confidential Names List). R1 was administered medication to which they are allergic. LPA obtained records and interviewed staff on this day.

LPA toured the facility and observed that the residents in care appeared appropriate for the facility. All staff the LPA interacted with had a current criminal record clearance.

A deficiency is cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 8, and is noted on the attached LIC809-D for this medication error.

An exit interview was conducted with Sondra Brakeville, Administrator/Executive Director. A copy of this report and appeal rights (LIC9058 03/22), were provided via hardcopy at the conclusion of the visit..
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 02:27 PM - It Cannot Be Edited

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: SILVERGATE RANCHO BERNARDO
FACILITY NUMBER: 374604323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited

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Incidental Medical & Dental Care Services. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:
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Facility administrator has agreed to conduct medication administration training and identifying allegies. Administrator agrees to provide proof of training of all Medication Technicians by POC due date of 01/13/2023.
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based on facility self-report and interviews with staff, R1 was administered another resident's medicaiton to which they were allegic. This poses an immediate health risk for 1 of 217 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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