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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 09/07/2023
Date Signed: 09/07/2023 10:52:56 AM


Document Has Been Signed on 09/07/2023 10:52 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
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: 69DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Robert SneeTIME COMPLETED:
11:05 AM
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On September 7, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit at the facility to follow up on an incident that was reported on 8/28/2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit.

The Licensee reported on 8/25/2023, Staff #1 (S1) reported to Administrator that he/she observed Staff 2 (S2) throw a cup of tea on Resident 1 (R1). In addition, S1 reported that he/she observed S2 on 7/25/2023 make contact with S2's hand to Resident 3 (R3).

During the visit, LPA discussed incidents with the administrator and director of health services. According to the interviewed staff, there were not witnesses for the two incidents being reported by S1. S2 was immediately suspended on 8/25/2023 and later terminated on 8/30/2023. Belmont Police, Ombudsman and all required parties were notified.

Administrator to send facility's internal investigation records to LPA by 9/8/2023.

No deficiencies are cited during visit. LPA to conduct a follow up visit if required.

Report is reviewed with Director of Health Services 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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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