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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 10/10/2022
Date Signed: 10/10/2022 01:51:23 PM


Document Has Been Signed on 10/10/2022 01:51 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: DATE:
10/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Director of Health Services, Amyda Astrero TIME COMPLETED:
02:00 PM
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On October 10, 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 October 3, 2022. 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 September 25, 2022, Resident #1 (R1) and Resident #2 (R2) were found in R2's room. It was indicated R2 was agitated and screaming because R1 touched him/her. According to the Director of Health Services, R1 did not have a one on one caregiver assigned at this time.

During the visit, LPA reviewed R1's file and interviewed staff. According to the file reviewed, R1 has a diagnosis of dementia. In addition, R1 has had a prior incident where R1 was found naked in another resident's bed. According to the interviewed staff, R1 has a new Geriatric doctor in which the facility has been in communication with daily, and R1's medications have been adjusted. In addition, Director of Health Services and Assistant Director of Health Services, indicated R1 has an one on one caregiver assigned around the clock and has notified all required parties. The facility had a care team meeting to discuss R1's behaviors and future care plans and has been in touch with R1's responsible party on a daily basis.

No citations issued during the visit. LPA reviewed report with Director of Health Services, Amyda Astrero and Assistant Director of Health Services, Hazel Yabut and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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