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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:44:22 AM


Document Has Been Signed on 05/24/2022 11:44 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
CCLD Regional Office, 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: 66DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Interim Administrator, Robert SneeTIME COMPLETED:
12:00 PM
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On May 24, 2022, Licensing Program Analyst (LPA) conducted an unannounced case management visit. LPA met with interim Administrator, Robert Snee, and Director of Health Services, Glynis Marcantel joined shortly thereafter. LPA explained the purpose of the visit.

The licensee reported on May 13, 2022, Resident (R1) was observed by the front receptionist to be walking toward the main office. According to R1, it was indicated at first that he/she jumped over the fence, however R1 then stated he/she had walked through the gate. There were no injures noted.

During the case management visit, LPA interviewed staff and reviewed R1's files. According to the file reviewed, it indicates that R1 has dementia and is unable to leave the facility unassisted. According to the staff interviewed, it was indicated that the latch on the gate may not have been latched all the way resulting to R1 walking out of the facility.

Facility immediately conducted a head count of all residents and checked to ensure all the gates were locked. In addition, the facility had a locksmith company come and perform an inspection of all gates to ensure they were locked and latched properly, however, these precautions were conducted after R1 was able to leave the facility. Section 87411(a) Personnel Requirements, requires that facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary care and supervision to meet resident needs. In the above incident, there was an absence of supervision resulting in a resident leaving the facility.

87411(a) Personnel Requirements- $500 CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION WITHIN 12 MONTHS on 2/24/2022.

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 Robert Snee, and Glynis Marcantel and a copy will be provided with appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/24/2022 11:44 AM - 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
CCLD Regional Office, 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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/31/2022
Section Cited

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87411 Personnel Requirements: (a) acility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

Violation of this regulation is not met as evidence by:
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Facility will have all staff members enter and exit from the main office. Staff will also be reminded to ensure gates are latched all the way if they go through the gates.
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Based on staff interviews and file reviewed, it was indicated that Resident (R1) has dementia and is unable to leave the facility unassisted. In addition, it was indicated that there was no staff member who observed R1 leave the facility until R1 was observed walking toward the main office. Nevertheless, there wa no staff member present to supervise the resident. This poses a potentional health and safety risk to 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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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