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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 02/24/2022
Date Signed: 02/24/2022 12:18:18 PM


Document Has Been Signed on 02/24/2022 12:18 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: 66DATE:
02/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Health Services, Glynis MarcantelTIME COMPLETED:
12:30 PM
NARRATIVE
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On February 24, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an Incident Report. LPA was greeted by
the Director of Resident and Family Services, Diane Sapienza-Boundy, and the Director of Health Services, Glynis Marcantel, joined shortly thereafter. LPA Charitra explained the purpose of the visit.

The licensee reported that on January 19, 2022, two residents were involved in an unwitnessed altercation. The staff walked into the library and saw a resident on the floor (R1). Another resident (R2) was trying to make a phone call and Resident (R1) attempted to grab the receiver. Somehow R2 hit R1 with the receiver.

During the case management, LPA observed R1 being changed in her bed and R2, in the dining hall watching television. LPA interviewed staff and reviewed both resident’s files. According to the files reviewed and the documentation collected indicates that R1 has a diagnosis of Dementia with behavioral disturbances while R2 has a diagnosis of Alzheimer’s and Pseudobulbar.

This is the second altercation involving R1 without any staff being present since November 2021 (see LIC809 dated 11/15/2021). In November was reported that staff had left R1 and another resident alone in the dining room, and when staff walked in observed that R1 was kicking the other resident. The report of January 19, involving R1 and R2 noted above, indicate that there was no staff member around or physically present in the library supervising the residents. The licensee has indicated that no one-on-one supervision is provided unless it is paid by the resident; however, Regulation requires the licensee to provide sufficient staff to meet the residents’ care and supervision. In the above incidents, there was an absence of supervision resulting in altercation between residents.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

Report is reviewed with Glynis Marcantel and a copy will be provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 02/24/2022 12:18 PM - 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
CCLD Regional Office, 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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2022
Section Cited

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Personnel Requirements: Facility personnel shall at all times be sufficient in numbers... to provide the services necessary to meet resident needs...Sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608.... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Violation of this regulation is evidence by staff interviews indicating that R1 and R2, both with dementia, were alone in the library without a staff member present to supervise the residents. Staff were aware of R1’s aggressive behaviors due to 2 prior altercations involving R1; November 10, 2021 and January 18, 2022 but failed to provide additional supervision. Although it was acknowledged by the facility that R1 demonstrates violent and aggressive behaviors, and the goal will be to ensure R1 does not cause injury to self or others, the facility failed to provide an appropriate intervention to identify R1’s needs in order to avoid similar behavioral and physical situations moving forward.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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