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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 07/18/2022
Date Signed: 07/18/2022 10:47:38 AM


Document Has Been Signed on 07/18/2022 10:47 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SILVERADO SENIOR LIVING - BELMONT HILLSFACILITY NUMBER:
415600869
ADMINISTRATOR:JOAN D NEWMANFACILITY TYPE:
740
ADDRESS:1301 RALSTON AVETELEPHONE:
(650) 654-9700
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:112CENSUS: DATE:
07/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Staffing Coordinator, Maria Miller TIME COMPLETED:
10:55 AM
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On July 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on July 11, 2022. LPA met with Staffing Coordinator, Maria Miller and Director or Resident and Family Services, Kate Rickard joined shortly thereafter. LPA explained the purpose of the visit.

The Licensee reported on July 11, 2022, Resident #1 (R1) was observed by a caregiver (S1) climbing over the facility gate. S1 immediately ran towards R1 and called for help. R1 was already on the other side of the gate by the time S1 got to the gate. R1 was observed outside the community, walking up the hill to the twin pine park. Staff members followed R1 and tried redirecting him/her to the facility, however R1 refused. Medications were administered to R1 and R1 became cooperative and returned back to the community.

During the visit, LPA reviewed R1's files and interviewed staff. Files reviewed indicated that R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. According to the staff interviewed, R1 is a newly admitted resident and has a history of elopement from previous facility. According to R1's file, R1 eloped from a facility by climbing a 10ft wall.

The facility notified responsible party and R1's physician. R1's physician adjusted R1's medications and a one on one caregiver was assigned.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

Report is reviewed with Staffing Coordinator, Maria Miller and Director or Resident and Family Services, Kate Rickard and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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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Document Has Been Signed on 07/18/2022 10:47 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS
FACILITY NUMBER: 415600869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2022
Section Cited

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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

Violation of this regulation is not met as evidenced by:
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Based on interviews conducted and file reviewed, although R1 is a newly admitted resident, R1 has a history of elopement from his/her previous facility by climbing a wall. In addition, file reviewed indicated R1 has a diagnosis of Alzheimer's dementia and is unable to leave the facility unassisted.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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