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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200938
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:50:33 PM

Document Has Been Signed on 10/08/2024 02:50 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/
DIRECTOR:		EMORUWA, JEFFREY OFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STREETTELEPHONE:
(949) 240-7200
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY: 90CENSUS: DATE:
10/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Durga Acharya, Receptionist TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 10/08/24 around 01:45 PM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding reporting requirements. LPA met with Durga Acharya, Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting.

On 09/13/24,LPA L. Holmes received an email from LPA L. Sampair with COVID-19 report and death reports that were provided to licensing from the facility. Five (5) of the ten (10) reports sent by Silverado Berkeley were late and did not meet the regulatory guidelines for notifications and reporting. LPA requested that ADM advise CCLD when the facility has been cleared of COVID-19 so that a case management could be conducted for late reporting of the deaths and incidents that had occurred during the month of August. On 09/16/24, ADM advised that the facility did not have any COVID-19 cases and essentially the facility was clear. ADM stated that he’d speak with their Director of Health Services to find out more about the late reporting.

Based on information obtained the deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.


Exit interview conducted, appeal rights, and copy of this report provided to Durga Acharya, Receptionist .

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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Document Has Been Signed on 10/08/2024 02:50 PM - It Cannot Be Edited


Created By: Lisha Holmes On 10/08/2024 at 01:59 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: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
Section Cited
CCR
87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by:
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ADM agreed to conduct in-service staff retraining on reporting in a timely manner and submit to CCLD completed certifications as proof of correction.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident reports to CCLD within seven days which poses a potential health and safety risk to the 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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