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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:35:26 PM


Document Has Been Signed on 03/17/2023 02:35 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:ROBERT SNEEFACILITY TYPE:
740
ADDRESS:1301 RALSTON AVETELEPHONE:
(650) 654-9700
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:112CENSUS: DATE:
03/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Robert SneeTIME COMPLETED:
02:45 PM
NARRATIVE
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On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management. LPA met with Administrator, Robert Snee and explained the purpose of the visit.

The Department is amending the licensing report dated April 29, 2022 for complaint control number 14-AS-20220216135656 as per the February 24, 2023 First Level Appeal Response and reissuing the Reporting Requirements citations for Section 87211(a)(1) and Section 87211(b) as one violation.
 
Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator 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: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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 03/17/2023 02:35 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: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited

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87211: Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(b) “Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1)”.

Violation of this regulation is evidenced by:
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On 5/4/22, facility submitted acknowledgement of Title 22 regulations for reporting requirements 87211. POC was cleared on 5/6/22 by LPA
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The facility failed to provide the LIC624 and SOC341 to the Department within regulatory timeframes for the incident of alleged abuse that occurred on February 13, 2022.
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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: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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