Silvergate Fallbrook Retirement Residence

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Tremayne Barra and Abdoulaye Zerbo arrived unannounced to conduct an annual inspection. Upon arrival LPA's were greeted by facility staff and granted entry after signing in. LPA's began inspection with introduction and the purpose of the visit. Upon arrival LPA's learned that one-hundred and fifteen (115) residents live at this facility. The Executive Director, Janae Orona was advised of the annual and conducted and completed the facility tour. Residents Records/Incident Reports/Residents Rights Information: LPA's reviewed residents' records. Ten (10) records were reviewed. LPA's reviewed the identification and emergency information, the admission agreement, the medical assessment, the TB test results, the needs and service plans, the placement, the functional assessment, the centrally stored medication/destruction records, the safeguard for personal property/valuables, and the personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA's reviewed Ten (10) employee records including first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current Administrative organization. The Administrator’s certificate expiration date was 03/26/2026. Food Service: Food preparation areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. Sharps are located in the kitchen and inaccessible to the residents in care . Physical Plant and Safety of Environment/Operational Requirements: LPA's toured the facility inside and outside. LPA's observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the residents' comfort. Lighting is sufficient for safety. Water temperature measured 120.0 degrees F. Laundry is done in the designated laundry room, in each building. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the housekeeper’s designated closet. All outdoor and indoor passageways are free of obstruction. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are zero (0) pools at the facility. The last emergency fire drill was conducted on 01/28/2026. Infection Control: The LPA's observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA's observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA's reviewed the facility's infection control plan which met department requirements. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication room. LPA's reviewed medication for three (3) residents confirming that all medications were listed and accounted. LPA's made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA's observed several smoke detectors and carbon monoxide detectors throughout the facility. The last fire inspection conducted by the North County Fire Protection was on 01/14/2026. There were several fire extinguishers on site throughout the facility, date charged was 11/06/2025. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed, and a copy of this report was provided to Executive Director, Janae Orona.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred and five (105) residents live at this facility. The Executive Director, Janae Orona was advised of the annual and conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Janae Orona, Administrator’s certificate expiration date was 03/26/2026. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the designated laundry room, in each building. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the housekeeper’s designated closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) fireplaces at this facility. There are zero (0) pools at the facility. LPA observed emergency supplies and two (2) first aid kits, located in each of the faclity’s medication room. The last emergency fire drill was conducted on 01/09/2025. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed several smoke detectors and carbon monoxide detectors throughout the facility. The last fire inspection conducted by the North County Fire Protection was on 05/15/2024. There were several fire extinguishers on site throughout the facility, date charged was 11/25/2024. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Janae Orona.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required/annual visit. LPA was greeted and granted entry by receptionist Josefina Cornejo. The Executive Director Patricia Martinez then greeted LPA, where LPA the purpose of the visit. LPA conducted a review of the facility personnel roster and observed for all staff that LPA came in contact with to have obtained proper fingerprint clearance, and to be associated to the facility. The facility is licensed licensed to serve one hundred forty five (145) elderly residents, that may have dementia; all of whom may be non-ambulatory, twelve (12) that may be bedridden. The facility has an approved hospice waiver for sixteen (16) residents. There are currently seven (7) residents on hospice. LPA conducted a tour of the interior and exterior of the facility. LPA observed the following: The facility is currently painting/touching up the exterior of the facility. Per Executive Director Patricia Martinez there is also current roof repairs being completed as a result of the recent rain. The facility was observed to be clean, clutter and odor free. Most of the residents were observed to enjoy socializing with one another listening to music during happy hour. The facility has multiple smoke and carbon monoxide detectors strategically placed throughout the facility. Detectors in each building were randomly checked and were observed to be operable. There are several fire extinguishers throughout the community that were observed to be fully charged. The facility is conducted emergency disaster drills on a quarterly basis, the last drill conducted was on 1/25/24. The next upcoming drill is scheduled for March 2024. The facility has a functional signal system that operates from each resident bedroom. As each resident bedroom has pull cords, they were randomly checked and observed to be operable. Sharps, disinfectants, cleaning solutions, and poisons are locked and were observed inaccessible to residents. There are known no guns or ammunition on the premises. The hot water temperature was checked randomly in resident bathrooms in all three (3) buildings. The hot temperature was found to be within regulatory limits ranging from 106.6-114.4 degrees F. A tour was conducted of the kitchen, LPA observed dining staff prepping for dinner, and the surfaces used to prepare the food was observed to be clean. The facility was observed to have a 7 day supply of non-perishable and a 2 day supply of perishable food items. The refrigerators were clean, organized and all food was properly stored. The medications were observed to be in a locked place that is inaccessible to residents. The facility requires all medical staff to have a current First Aid/CPR training. Resident files were reviewed and found to have the required documents (physician's report/physical, appraisal/needs and services plan and admission agreement). Mrs. Patricia Martinez will provide a copy of the facility's current liability insurance to the regional office for the facility file. Based on today's inspection no deficiencies were observed. An exit interview was conducted and a copy of this report was provided to Patricia Martinez, Executive Director.the state’s words, verbatim · CDSS document, Feb 22, 2024