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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 10/17/2022
Date Signed: 10/17/2022 01:32:59 PM


Document Has Been Signed on 10/17/2022 01:32 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: 69DATE:
10/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Director of Health Services, Amyda AstreroTIME COMPLETED:
01:45 PM
NARRATIVE
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On October 17, 2022, Licensing Program Analyst (LPA) Komal Charitra and Licensing Program Manager (LPM) Cara Smith conducted an unannounced case management visit to follow up on a visit made on October 10, 2022. LPA and LPM met with Director of Health Services (DHS), Amyda Astrero and Administrator, Robert Snee, joined shortly thereafter. LPA explained the purpose of the visit.

On October 10, 2022, LPA conducted a case management visit to follow up on an un-witnessed incident that occurred on September 25, 2022 where Resident #2 (R2) was screaming and agitated and verbalized Resident #1 (R1) touched R2's breast and shook it.

During the visit, LPA Charitra and LPM Smith toured the facility with DHS, Amyda Astrero and observed R1 sleeping in bed with his/her one on one caregiver in the room. LPA and LPM reviewed R1's file and needs and service plan. In addition, LPA Charitra and LPM Smith interviewed DHS and Administrator regarding R1. According to the Administrator and DHS, R1 has a new Geriatric doctor that has been in communication with the facility. In addition, it was indicated that R1 is on new medications prescribed by the new doctor.

According to the file reviewed, R1 was admitted to the facility on May 3, 2022 and this incident is his/her fifth incident at the facility, three of which are of R1 displaying inappropriate behaviors towards female residents. In addition, based on R1's needs and service plan, R1 has a history and pattern of aggressive and inappropriate behaviors towards residents. Although facility has interventions in place, R1 has re-occurring incidents.

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 Director of Health Services (DHS), Amyda Astrero and Administrator, Robert Snee, and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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 10/17/2022 01:32 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
SF COASTAL AC/SC, 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: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment

Violation of this regulation is not met as evidenced by:
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Based on the interviews conducted and the file reviewed, R1 has a history of aggressive and inappropirate behaviors towards other residents in care. Furthermore, due to R1's inappropriate behaviors, the facility environment is not comfortable for other residents in care.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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