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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 12/19/2023
Date Signed: 12/19/2023 10:42:58 AM


Document Has Been Signed on 12/19/2023 10:42 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: 70DATE:
12/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Robert SneeTIME COMPLETED:
11:00 AM
NARRATIVE
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On December 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on December 10, 2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit.

On December 10, 2023, the Licensee reported that a staff member observed Resident 1 (R1) and Resident 2 (R2) in the room together. It was reported that R1 was touching R2's chest area. R1 has a 24/7 one-on-one private caregiver assigned to him/her, however during the time of the incident, the private caregiver went to use the restroom and left R1 unattended without telling a staff member.

During the visit, LPA reviewed R1's file, interviewed administrator and director of health services. According to Administrator and Director of Health Services, agency caregivers are required to contact the nurse's station and notify a staff member prior to going on break/lunch so a staff member can be assigned to be R1's companion while the agency caregiver is on break. Based on R1's file, this is the the third incident involving R1 touching another resident inappropriately; previous incidents occurred 11/7/2023 and 11/8/2023. A 24/7 private agency caregiver was assigned on 11/8/2023.

Facility was unable to provide LPA an orientation checklist or training provided to the private one-on-one agency caregiver regarding breaks/lunches. Based on documents reviewed and interviews conducted, facility failed to provide orientation/training to the private on-on-one agency staff member assigned to R1 which resulted to R1 being left unattended. Nevertheless, due to R1 being left unattended, R1 was observed in the room with R2 touching his/her breasts.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with the administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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 12/19/2023 10:42 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
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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to create a checklist and/or documented training for all one-on-one agency caregivers. Checklist/training to include; protocols when taking breaks and lunches.
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Based on interviews conducted and documents reviewed, the facility failed to provide orientation/training to the private on-on-one agency staff member assigned to R1 which resulted to R1 being left unattended. Nevertheless, due to R1 being left unattended, R1 was observed in the room with R2 touching his/her breasts.
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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: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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