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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:33:39 PM


Document Has Been Signed on 05/03/2023 01:33 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: 64DATE:
05/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Robert Snee TIME COMPLETED:
01:45 PM
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On May 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on April 22, 2023. LPA met with Administrator, Robert Snee, Director of Health Services, Amyda Astrero and Assistant Director of Health Services, Hazel Yabut and explained the purpose of the visit.

On May 1, 2023, the Licensee reported that a caregiver heard R1 shouting for help while being in the Maple dining room. According to the Licensee, the caregiver found R2 sitting on R1 with one hand on R1's chest and the other hand between R1's legs.

During the visit, LPA discussed the incident with Administrator, Director of Health Services, and Assistant Directors of Health Services and reviewed resident files. According to the Administrator, this incident occurred after dinner when caregivers were assisting put residents to bed. The Director of Health Services indicated that the caregiver immediately responded to R1 as his/her room is near the Maple dining room.

Based on R1 and R2's file, both residents have a diagnosis of dementia. According to the Director of Health Services and file reviewed, R2 does not have a history of touching residents, however he/she does have a wandering behavior where he/she wanders in the hallways or other residents rooms.

During the visit today, LPA observed a one on one caregiver with R2. In addition, R2's medication dosage was increased. Furthermore, Administrator indicated that R2's room was changed to the Cedar building.

No citations issued during this time. Report is reviewed with Robert Snee, Amyda Astrero, and 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: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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