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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:33:26 PM


Document Has Been Signed on 07/19/2022 01:33 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, 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:
07/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Interim Administrator, Robert SneeTIME COMPLETED:
01:40 PM
NARRATIVE
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On July 19, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCLD. LPA met with Interim Administrator, Robert Snee and Director of Resident and Family Services, Kate Rickard and explained the purpose of the visit.

The Licensee reported on July 15, 2022, Resident #1 (R1) was observed by a caregiver laying besides Resident #2 (R2), who was fully clothed and sleeping during the time. Caregiver immediately redirected R1 and called for additional help.

During the case management visit, LPA observed R1 eating lunch in the dining room with his/her private caregiver. In addition, during the visit, LPA interviewed staff and reviewed R1's file. According to R1's file reviewed, R1 has a diagnosis of dementia. Interviewed staff indicated that a private caregiver was assigned to R1, and R1 will have a full work up conducted on 7/20/22 by R1's primary care physician. It was also indicated that R1's medications will be adjusted.

This is the second unusual behavior involving R1, as the other incident occurred on 5/26/22, where R1 was found in a female resident's room. (see LIC809 dated 6/16/2022). Due to staff's lack of supervision, R1 a dementia resident, was able to walk into R2's room and lay besides him/her.

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 Interim Administrator, Robert Snee and a copy is provided with the appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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 07/19/2022 01:33 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, 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2022
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 the file reviewed and interviews conducted, R1 has a diagnosis of dementia. In addition, staff were aware of R1's prior history of unusual behavior that occurred on 5/26/22 but failed to ensure another unusual incident involving R1 will occur.
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Facility assigned R1 a private caregiver. Facility contacted physician for medication adjustment. A full work up will be conducted by R1's phsycian on 7/20/22.

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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: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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