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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 12/23/2024
Date Signed: 12/23/2024 05:06:15 PM

Document Has Been Signed on 12/23/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR/
DIRECTOR:		TANA MCMILLONFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 70CENSUS: 39DATE:
12/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Ashiman Gill, Administrator and Libbie Retts, Director of Health ServicesTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to the facility at 1:45 pm. LPA was greeted and granted entry by the Concierge and met with Ashiman Gill, Administrator (AD) and LIbbie Retts, Director of Health Services (DHS) and stated the purpose of the visit

LPA interviewed three of three staff members regarding the Unusual Incident Report received in the Regional Office on December 23, 2024. LPA interviewed two of two resident family members.
LPA requested the following resident records: Identification and Emergency Information, Appraisal, Physician's Report, Physician Order Review, and Incident Progress Notes. LPA also requested staff files and the staffing schedule for care staff and engagement staff for December 20, 2024. LPA was also shown video footage of the incident.

Based on the interviews and observations made during today’s visit, LPA will need to further investigate the incident. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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