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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 04/30/2021
Date Signed: 04/30/2021 02:26:58 PM

Document Has Been Signed on 04/30/2021 02:26 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
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: 70DATE:
04/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joan D Newman TIME COMPLETED:
02:25 PM
NARRATIVE
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On April 30, 2021, Licensing Program Analyst (LPA) Shabana Buksh conducted an unannounced follow up case management inspection. This inspection was conducted regarding the unusual incident that occurred on 03/29/2021. CCLD was informed through unusual incident report from facility. Administrator, Joan Newman and the staff who witnessed the incident were interviewed. Administrator provided all requested documents for review. LPA obtained police report for review. Based on interviews, record reviews, and all information collected during this investigation, the following deficiency of the California Code of Regulations, Title 22, Division 6, is cited. Appeal rights given.



LPA sent the report to Administrator for review and signature.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Shabana Buksh
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2021
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 04/30/2021 02:26 PM - It Cannot Be Edited


Created By: Shabana Buksh On 04/30/2021 at 10:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2021
Section Cited
CCR
87468.1(a)(3)

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87468.1
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination
This requirement is not met evidenced by:

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Adminstrator agreed to develop a written plan of correction (POC) describing how facility shall ensure compliance with 87468.1(a)(3). POC shall include measures to be implemented to prevent a repeated occurrence.
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Based on reviews and interviews, Licensee failed to protect residents personal rights which posed an immediate Health, Safety and Personal rights risk to residents in care.
Staff was observed by another staff being abusive to residents.
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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:Brenda Chan
LICENSING EVALUATOR NAME:Shabana Buksh
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2021


LIC809 (FAS) - (06/04)
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