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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 03/15/2024
Date Signed: 03/15/2024 01:49:16 PM


Document Has Been Signed on 03/15/2024 01:49 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: 75DATE:
03/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Robert SneeTIME COMPLETED:
02:00 PM
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On March 15, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCL. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit.

The Licensee reported on March 11, 2024 at approximately 12:05pm, Resident 1 (R1) was found by Resident Care Coordinator outside near the community parking lot in a wooded area. R1 was escorted back into the community and was assessed by the nurse. Based on facility's internal investigation, perimeter gates were all closed, locked and in working order; no evidence of equipment or rocks were visible to indicate gate was propped open. There were no signs of equipment or furniture to indicate that R1 could've climbed the gates. Facility initiated behavior mapping for R1 and conducted rounds to ensure all gates were locked and secure.

In addition, on the same day, March 11, 2024 at approximately 6:25pm, while conducted rounds, staff reported that R1 was not in the dining room. Staff immediately started searching for R1. Med-tech found R1 walking around on the other side of the gates near the Bay neighborhood, close to a picnic area. R1 was redirected back into the community, assessment was done by nurse, and a one on one caregiver was assigned to R1. Community perimeters were checked again, all gates were observed locked. Locksworth Unlimited inspected the gates.

During the visit, LPA reviewed R1's file, observed R1 eating lunch. R1 is currently residing in Twin Pines neighborhood where there is more staff present. Based on R1's file, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. Behavior mapping log was observed. Facility conducted 30-minute status checks after the first incident occurred at 12:05pm. According to Administrator and Director of Health Services, R1 does not have a history of AWOL, however R1's responsible party takes R1 out of the community for several days at a time which; recent outing was hiking from 3/5/2024 - 3/10/2024. Updated service plan was observed.

No citations issued during the visit. Report is reviewed with Administrator 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: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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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