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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:42:24 PM


Document Has Been Signed on 12/06/2023 01:42 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: 69DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Administrator, Robert SneeTIME COMPLETED:
02:00 PM
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On December 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on two incidents that was reported to CCLD. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit.

The Licensee reported on 11/7/2023, Resident 1 (R1) was observed holding Resident's 2 (R2's) hand. It was observed by a caregiver that R1 reached over and touched R2's breasts. Caregiver immediately separated R1 and R2. R1 was placed on 30-minute checks, facility called responsible party to request a one-on-one caregiver, and facility called R1's physician to review R1's medications.

The Licensee reported on 11/8/2023 around 4:30pm, R1 observed walking by R2 and gilded his/her hang over Resident 3's (R3's) breast area. Caregiver separated both residents at the time. One one one caregiver for R1 was provided at 6:30pm on 11/8/23, physician adjusted R1's medication, behavior mapping is on-going.

During the visit, LPA reviewed R1's file, observed R1 and discussed the incidents with Administrator and Director of Health Services. Based on R1's record review, R1 has a diagnosis of Alzheimer's Dementia and does not have any inappropriate or aggressive behaviors. Based on observations, R1 was in the dining room with R1's one-on-one caregiver. According to the administrator and director of health services, R1 has not had any inappropriate incidents since the one-on-one caregiver was assigned and facility will continue to monitor R1. Director of Health Services will set up a meeting with R1's physician and responsible party and conduct a re-assessment for R1.

No deficiencies are cited today. Report is reviewed with Administrator and 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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