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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:08:58 PM

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: DATE:
11/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Joan NewmanTIME COMPLETED:
02:00 PM
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On November 15, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Case Management visit regarding an Incident Report that was received on November 10, 2021. LPA was greeted by the Administrator, Joan Newman and the Director of Health Services, Glynis Marcantel joined shortly thereafter. LPA Charitra explained the purpose of the visit

During today's inspection LPA observed the residents. Residents were observed to be in the dining room together at this time. LPA interviewed staff and reviewed resident documents and the admission agreement. According to the admission agreement, the residents are able to remain independent, roam around the facility and actively engage in the community alone.

According to the Incident Report, Resident 1 (R1) was observed to be kicking Resident 2 (R2). Residents have a diagnosis of Dementia with Behavioral Disturbances and were left alone in the dining room when the incident occurred. Based on the Administrator and the Director of Health Services, this was a one time altercation between the residents, no prior history of physical abuse. The facility does not provide one on one care to the residents unless stated otherwise. LPA reviewed the Needs and Service Plan for both R1 and R2 and it states residents do not require hands on assistance.

Facility informed Ombudsman, Licensing, Physicians, and the resident's Responsible Party regarding this Incident.

No deficiencies were issued.

Report was reviewed with Administrator
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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