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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604323
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:56:59 PM

Document Has Been Signed on 05/23/2022 03:56 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SILVERGATE RANCHO BERNARDOFACILITY NUMBER:
374604323
ADMINISTRATOR:BRAKEVILLE, SONDRAFACILITY TYPE:
740
ADDRESS:16061 AVENIDA VENUSTOTELEPHONE:
(858) 451-1100
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 285CENSUS: 219DATE:
05/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Diana Lopez, Director of Resident Care, Sondra Brakeville, Executive Director and Jessica Swaaley, Business Office Manager TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA was greeted and identified herself to the receptionist. LPA then met and discussed the purpose of the visit with Sondra Brakeville, Executive Director.

Today’s visit is regarding two self- reported incidents submitted to Community Care Licensing (CCL). The first incident involves Resident #1, (R1) (See LIC 811 Confidential Names List for identification of R1) falling and sustaining an injury on 5/7/22. R1 was transported to the hospital for evaluation. R1 returned to the facility on 5/8/22 and is receiving hospice services.

The second incident involves Resident #2 (R2) (See LIC 811 Confidential Names List for identification of R2) sustaining an injury after falling in the bedroom on 5/13/22. R2 was transported to the hospital for evaluation. It was discovered at the hospital that R2 sustained an injury from the fall.

LPA briefly toured the facility, interviewed staff, and reviewed records. No deficiencies observed during today’s visit.

An exit interview was conducted with Jessica Swaaley, Business Office Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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