Silvergate Rancho Bernardo

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Jessica Swaaley. The facility's license shows a maximum capacity of two hundred eighty five (285) non-ambulatory residents, ages 60 and over, of which fifty (50) may be bedridden. Approved Hospice waiver for fifty (50). During today’s inspection there were 198 residents in care. LPA and Executive Director Jessica Swaaley toured the interior and exterior of the facility and inspected a sample of rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. A pools exists on the premises which was inaccessible to residents. Per Executive Director Jessica Swaaley, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Jessica Swaaley to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 25, 2026

Allegation investigated: Facility does not provide a safe environment for residents.

LPM II, RA, Donna Teutschel conducted a telephone interview with facility Administrator, Sondra Brakeville. The allegation refers to an issue that the facility main front door is locked at night and that residents are unable to exit at night through the facility main front door and facility night security staff are not always available at the front desk to assist. Based upon interviews obtained, the facility has two side exit doors which are always unlocked. The facility front door is locked from the outside but not the inside which means any resident is able to exit at night. Each resident is issued a key fob should they be out for the evening and return to re-enter the facility which unlocks the front door and also have the ability to access or leave through the facility side doors. With respect to security staff, there are reasons from time to time they will step away from the front desk for various reasons. Based upon this information, the allegation is deemed Unsubstantiated. Administrator will be emailed licensing report: SBRAKEVILLE@AMERICAREHR.COM Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2025 · control 08-AS-20210216103426

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced required annual visit. LPA was allowed entry by Sondra Brakeville, Administrator. LPA identified herself and disclosed the purpose of the visit with the Administrator. Physical Environment: The facility was found to be clean, well-maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, was present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications following licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage at all times. Continued on 809C Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be following the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies, and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted, and a copy of this report, along with the Licensee Rights (LIC 9058) was provided to Sondra Brakeville, Administrator. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jun 4, 2025

Type of visit: Case Management - Incident

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 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.the state’s words, verbatim · CDSS document, Jan 17, 2025

Allegation investigated: Licensee did not ensure that a skilled professional was administering a resident's oxygen as prescribed Licensee did not ensure that a resident's oxygen equipment was operable Licensee does not ensure that a resident's dietary needs are being met Licensee is not adhering to the admission's agreement Licensee does not ensure that residents are provided individual privacy in the shower area Licensee does not maintain facility at a comfortable temperature for resident

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations LPA was allowed entry by Sondra Brakeville, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Administrator. On May 2, 2024, the Department received a complaint for the following allegations: Licensee did not ensure that a skilled professional was administering a resident's oxygen as prescribed, Licensee did not ensure that a resident's oxygen equipment was operable, Licensee did not ensure that a resident's dietary needs are being met, Licensee is not adhering to the admission's agreement, Licensee does not ensure that residents are provided individual privacy in the shower area, Licensee does not maintain facility at a comfortable temperature for resident. The investigation consisted of tour of the facility, interviews, review of records. Continued on 9099C Unsubstantiated On May 6, 2024, staff interviewed all stated that Resident 1 (R1) oxygen was being prescribed, R1's oxygen was initially prescribed as needed per the PRN then later became necessary to wear an oxygen mask at night to maintain an oxygen level above 90%. However, R1 would take the oxygen mask off at night which would cause levels to drop below 90%. R1 would need to have encouragement to keep the oxygen mask on but would refuse. The outside source also stated that R1 would not keep the oxygen mask on. The oxygen equipment was maintained at the request of the family but was not the responsibility of the facility. Since the oxygen was no longer prescribed as needed, and to be used nightly there was an additional charge by the facility. RP stated that they refused to pay for the additional charge. Staff and outside source stated that the resident's dietary needs were being met. The outside source and staff stated that the resident eats 3 times per day and takes Ensure as a supplement. RP did not state how the facility was not adhering to the admissions agreement and no examples were given. Staff interviewed stated that R1 was given privacy and staff were there to assist. The Maintenance Manager was interviewed and stated that the controls in the individual bedrooms control 3 to 4 bedrooms. If the temperature is set to a cooler temperature it affects all the rooms connected and vice versa for warmer temperatures. The residents would need to agree if they wanted their rooms to be cooler or warmer. Based on the investigation findings, the allegations made against the facility are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Sondra Brakeville, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 08-AS-20240502153636

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Sondra Brakeville, Administrator . LPA identified herself and disclosed the purpose of the visit with the Administrator. Physical Environment: The facility was found to be clean, well-maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage at all times. Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Sondra Brakeville, Administrator. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jun 19, 2024