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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:57:50 PM


Document Has Been Signed on 09/23/2022 12:57 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
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: 70DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director of Health Services, Amyda AstreroTIME COMPLETED:
01:15 PM
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On September 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on incidents that were reported to CCLD. LPA met with Director of Health Services, Amyda Astrero and Assistant Director of Health Services, Hazel Yabut and explained the purpose of the visit.

The Licensee reported on 9/7/22, Resident #1 (R1) and Resident #2 (R2) were heard yelling. Staff separated the resident and spoke to the residents. According to R1, he/she was hit on the left side of the chest by R2 and according to R2, R1 hit him/her on the arm. During the visit, LPA observed residents files and observed the residents. R1 was observed to be sleeping and R2 was observed to be eating lunch. Based on file reviewed, R1 and R2 has a diagnosis of Dementia. In addition, LPA reviewed R1's and R2's service plan and it indicated that facility is conducting behavior mapping and are keeping both residents apart from each other.

The Licensee reported on 9/9/22, Resident #3 (R3's) one on one caregiver reported that R3 hit R2. According to the Licensee, it was indicated that the R3 said something to R2, however R2 did not acknowledge resulting to R3 throwing juice on R2 and punching him/her on the left side of the chest. According to the Director of Health Services, R3's one on one caregiver was also punched by R3. During the visit, LPA observed R3 having lunch and observed a male one on one caregiver present. Based on file reviewed, R3 has a diagnosis of dementia and has been assigned a one on one caregiver since admission based on physician and responsible party due to agitation and wandering behavior.
LPA reviewed the needs and service plan for R3 and it indicates that physician adjusted his/her medication and behavior mapping is being conducted. In addition, the facility will ensure that there is a male one on one caregiver assigned to R3 at all times.

On 9/11/22, the Licensee reported an unwitnessed incident that Resident #4 (R4) was pulling down his/her pants to urinate. Resident #5 (R5) yelled at R4 resulting to R4 becoming agitated and slapping R5 in the face. During the visit, LPA observed both residents to be eating lunch. Based on file reviewed, both residents have a diagnosis of dementia. According to the Director of Health Services, R4 had a medication adjustment and a urine analysis was done. Behavior mapping is being conducted for both R4 and R5.

Report is reviewed with Director of Health Services and Assistant Director of Health Services and a copy is provided. No citations issued during the visit.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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