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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 09/12/2022
Date Signed: 09/12/2022 10:17:01 AM


Document Has Been Signed on 09/12/2022 10:17 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
SF COASTAL AC/SC, 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: 69DATE:
09/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Assistant Director of Health Services, Hazel YabutTIME COMPLETED:
10:25 AM
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On September 12, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on September 9, 2022. LPA met with Assistant Director of Health Services, Hazel Yabut and Administrator, Robert Snee. Director of Health Services, Amyda Astrero joined shortly thereafter. LPA explained the purpose of the visit.

The Licensee reported on September 7, 2022, Resident #1 (R1) was observed to have jumped over the facility fence near the activity office using a planter. Staff assisted R1 up, however R1 attempted to run after his wife who had just visited. Staff redirected R1 back to the facility. No injuries were noted.

During the visit, LPA observed R1 walking outside with his assigned one on one caregiver. LPA reviewed R1's files and interviewed staff. File reviewed indicates that R1 is a newly admitted resident that has a diagnosis of Parkinson's Dementia and is unable to leave the facility unassisted.

According to the Director of Health Services, Amyda Astrero and Assistant Director of Health Services, the facility notified R1's responsible party and R1's physician as required. R1's physician adjusted R1's medications and a one on one caregiver was assigned. Behavior mapping is still being conducted on resident.

No citations were issued during today's visit. LPA reviewed report with Director of Health Services and Assistant Director or Health Services and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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