415601073-11-12-2021-14-AS-JVAO-C8PTTT-20211112140115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601073
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:01:20 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 HILLS		FACILITY NUMBER:	415601073
ADMINISTRATOR:	JOAN D NEWMAN		FACILITY TYPE:	740
ADDRESS:	1301 RALSTON AVE		TELEPHONE:	(949) 240-7200
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	112	CENSUS:	DATE:	11/12/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Glynis Marcantel		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day at 1100hrs, Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced prelicensing inspection visit. LPAs met with diector of health services Glynis Marcantel and director of plant operations Gary and explained the purpose of today's inspection. LPAs toured the facility's buildings and grounds. Entire facility has hardwired smoke detectors and fire panel. Fire panel last inspected on 11/01/2021 and sprinklers last inspected on 11/02/2021 of which both are in full service. Facility does contain an emergency generator that will power facility for 72 hours. LPAs toured resident buildings. Twin Pines building is inspected. Room 507 was observed and water was tested at 116F. Room is fully furnished with appropriate lighting and furniture. Room is equipped with push button call system. Shower is clean and contains non-skid mat and grab bars. Fire extinguisher in dining room last inspected on 10/2021 and is charged ready for use. Carbon monoxide detector is present. Oak building is inspected. Room 405 and 411 were observed. Water was tested at 117F. Room is fully furnished with appropriate lighting and furniture. Room is equipped with push button call system. Shower is clean and contains non-skid mat and grab bars. Carbon monoxide detector is present. Maple building is inspected. Room 307 was observed and water was tested at 108F. Room is fully furnished with appropriate lighting and furniture. Room is equipped with push button call system. Shower is clean and contains non-skid mat and grab bars. Fire extinguisher in hall was last inspected on 10/2021. This building also contains resident incontinence supplies and some COVID related PPE. Carbon monoxide detector is present. Continued on next page...

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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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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: 415601073
	VISIT DATE: 11/12/2021

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Page 2 - Prelicensing

Cedar building is inspected. Room 212 was observed and water was tested at 115F. Room is fully furnished with appropriate lighting and furniture. Room is equipped with push button call system. Shower is clean and contains non-skid mat and grab bars. Carbon monoxide detector is present.

Additional COVID related PPE are located in a shed in the exterior area of the facility and in a closet in the library. Kitchen is inspected as well as fresh, frozen foods, and emergency food supplies. All food supplies are in place. Kitchen hood is due for cleaning and service on November 2021 but facility already has this scheduled to be conducted. Kitchen cooking range is due for cleaning as well as it was observed needing service. Cooking range and oven are operating. Facility has two wellness rooms which house the resident medications. These are observed and medications are properly stored and locked inaccessible to residents. Each resident building is equipped with a dining room and supplies are stored in refrigerators for resident use as well as juice and dining supplies. Sharps are not stored in these dining rooms.

Facility is in compliance with Title 22 regulations. No citations are issued.

Report is reviewed with Glenis.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC809 (FAS) - (06/04)

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