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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200938
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:03:34 PM

Document Has Been Signed on 03/23/2023 07:03 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SILVERADO SENIOR LIVING-BERKELEYFACILITY NUMBER:
019200938
ADMINISTRATOR:SNEE, ROBERTFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STREETTELEPHONE:
(949) 240-7200
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY: 90CENSUS: 73DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:25 PM
MET WITH:Jeff Emoruwa/Executive Director TIME COMPLETED:
07:00 PM
NARRATIVE
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While investigating a complaint (Control # 15-AS-20211124153927), and upon review of Unusual Incident Report (UIR), Licensing Program Analyst (LPA) Delmundo learned that the UIR for incident that happened on October 29, 2021 was submitted to the Department on December 7, 2021.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Jeff Emoruwa.

Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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 03/23/2023 07:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/23/2023 at 06:29 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SILVERADO SENIOR LIVING-BERKELEY
FACILITY NUMBER: 019200938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited
CCR
87211(a)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency ...: (1) A written report shall be submitted to the licensing agenc..... within seven days of the occurrence of any of the events(D) Any incident which threatens the welfar, safety or health of any resident..
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Excutive Director to conduct in-service training, and submit proof by 4/06/23.
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-This requirement is not met as evidenced by:
-Based on interview and records review, the licensee did not comply with the section above for not sending an incident report in timely manner when R1 pushed R2 which posed personal rights risk to persons in care
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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