<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604323
Report Date: 01/17/2025
Date Signed: 01/17/2025 11:53:07 AM

Document Has Been Signed on 01/17/2025 11:53 AM - 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:SILVERGATE RANCHO BERNARDOFACILITY NUMBER:
374604323
ADMINISTRATOR/
DIRECTOR:		BRAKEVILLE, SONDRAFACILITY TYPE:
740
ADDRESS:16061 AVENIDA VENUSTOTELEPHONE:
(858) 451-1100
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 285CENSUS: 212DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Jessica Swaaley, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Purpose of Visit: Incident Follow-Up – Death of Resident
Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with Jessica Swaaley, Executive Director, and discussed the purpose of the visit.

On January 13, 205, the facility sent the death report of Resident 1 (R1), age 78, to the Community Care Licensing Division (CCLD). The death occurred at the hospital after an unwitnessed fall at the facility.

According to the facility’s written incident report, R1 experienced an unwitnessed fall on January 10, 2025 at approximately 7:30 am. R1 was transported to the hospital for medical treatment. The Responsible Party (RP) informed facility that R1 passed away on January 13, 2025. No official diagnosis of cause of death has been made known by the hospital or medical examiner's office. Diagnosis fractured neck and breathing complications

Continued on 809C
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SILVERGATE RANCHO BERNARDO
FACILITY NUMBER: 374604323
VISIT DATE: 01/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Licensing Program Analyst (LPA) interviewed the Administrator and staff regarding the incident. The Administrator stated that staff followed the facility’s emergency protocols and contacted emergency services. Staff present during the incident confirmed that R1 was monitored per their care plan before the event.

Review of Records:  The primary diagnosis was Dementia "sun downing" no secondary diagnosis and not a fall risk per LIC 602A. The facility’s incident reports were submitted within the required timeframe and included all pertinent details. Observations of the facility revealed appropriate safety measures were in place; no environmental hazards were observed.

Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director along with appeal rights (LIC9058 03/22) and an LIC 811.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2