Facility Evaluation Report

Licensing Program Analyst’s (LPAs) Carmen Lopez and Ryan Fulton conducted an unannounced Case Management visit to cite deficiencies from a previous visit on May 6, 2020. LPA was greeted at the front door by Edgar Baltazar, Lead Concierge and granted entry after identifying themselves and disclosing the purpose of their visit. LPA discussed the purpose of the visit with Ada Navarrete, Director of Resident Care, Kristiana Lopez, Business Services Office Manager/Human Resource Manager, Joan Rink-Carroll, Director.

The facility submitted an Unusual Incident Report on April 27, 2020, advising that on or about April 20, 2020, at approximately 9:50am, Resident #1 (R1) had an unwitnessed fall and was found face down on the floor. According to the report, R1 sustained a skin tear above the right eyebrow and had a complaint of pain to the right shoulder.

R1 was admitted to Silvergate San Marcos Retirement Residence in October of 2017, to the Independent Living side of the facility and lived alone. Facility records revealed a fall risk assessment was completed, and that a score of 4 or more is at risk for falling. R1 was at a total of 2. R1’s Preplacement Appraisal dated October 17, 2017, listed no health or physical disabilities. R1 was able to ambulate, follow instructions, communicate their needs, complete all activities of daily living independently and leave the facility unassisted.

Facility Physician’s Report dated February 6, 2020 stated that R1 had a diagnosis of congestive heart failure (CHF), hypertension (HTN), hyperlipidemia, aortic valve disorder, orthostatic hypotension, iron deficiency and anxiety.

Interviews with staff revealed that R1 began having falls without injury. The facility staff spoke with family and agreed to move R1 to the Assisted Living side of the facility so that staff could keep a closer eye on the resident.