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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604254
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:22:26 PM

Document Has Been Signed on 10/03/2024 04:22 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SILVERADO SENIOR LIVING-ENCINITASFACILITY NUMBER:
374604254
ADMINISTRATOR/
DIRECTOR:		JOHNSON, MARIVELFACILITY TYPE:
740
ADDRESS:335 SAXONY ROADTELEPHONE:
(949) 240-7200
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY: 122CENSUS: 70DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Executive Director Marivel Johnson and Administrative Specialist Sabrina PegrossTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Jeffrey Keast. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross.

This visit is in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on October 2, 2024. The IR stated that there was an incident that transpired on Tuesday, September 24, 2024, with resident #1 (R1 – see LIC811 for confidential names list) who eloped from the facility. The facility made notifications to R1’s responsible party, their Medical Doctor (MD), and the Department.

During today's visit LPA Lopez briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified R1 eloped from the facility, but staff found R1 within about 15 minutes from notification that R1 was absent without leave (AWOL). Records showed that a wander guard was placed on R1 on 09/25/2024. R1’s service plan was updated on 09/23/2024 and on 09/24/2024 to include monitoring and elopement. Preplacement Appraisal did not indicate R1 had issues with elopement prior to admission. According to interviews R1 attempted to leave the facility once formerly, on Monday, 09/23/2024, but staff was always with R1 and they walked around the facility until R1 was ready to walk back in to the facility prior to the incident on 09/24/2024. The incident on 09/24/2024 was R1’s first AWOL from the facility since their move to the facility. Staff interviewed said they had assigned locations as to where they needed to look. Some staff drove around while others walked to the nearest locations in search of R1. R1 was found within the vicinity of the community unarmed within minutes of notifications being made.

(Continuation on LIC809-C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS
FACILITY NUMBER: 374604254
VISIT DATE: 10/03/2024
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(Continuation of LIC809)

R1’s Elopement Plan states that if a resident, such as R1, is not found within the initial sweep of the community and immediate surrounding area, notifications should be made to the local police, residents’ physician and responsible party. R1 was found within the vicinity of the community about 15 minutes after notifications were made that the resident was missing. Associates may be assigned to drive around the area. In review of the procedure and staff interviewed, the facility’s elopement procedure was followed.

No deficiencies were cited during today’s visit.

LPA informed Administrative Specialist Sabrina Pegross that there may be possible follow-up telephone calls or visits for this incident.

An exit interview was conducted with Administrative Specialist Sabrina Pegross, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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