Inspection Reports for
Silvergate Rancho Bernardo

CA, 92128

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 0.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

90% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 100% occupied

Based on a June 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

120 160 200 240 280 320 Jan 2021 Jan 2022 Jan 2023 Mar 2023 Jan 2025 Jun 2025

Inspection Report

Complaint Investigation
Capacity: 285 Deficiencies: 0 Date: Jul 9, 2025

Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility does not provide a safe environment for residents, specifically concerning the facility's main front door being locked at night and residents' ability to exit.

Complaint Details
The complaint was unsubstantiated after investigation. The allegation involved concerns about resident safety related to locked front doors and security staff availability at night.
Findings
The investigation found that the facility's main front door is locked from the outside at night but not from the inside, allowing residents to exit. Two side exit doors remain unlocked at all times. Residents have key fobs to re-enter the facility. Security staff may occasionally be away from the front desk, but overall the allegation was deemed unsubstantiated.

Report Facts
Facility capacity: 285

Employees mentioned
NameTitleContext
Donna TeutschelLicensing EvaluatorConducted the complaint investigation and telephone interview with the facility administrator
Sondra BrakevilleAdministratorFacility administrator interviewed during the investigation

Inspection Report

Complaint Investigation
Capacity: 285 Deficiencies: 0 Date: Jul 9, 2025

Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-02-16 alleging that the facility does not provide a safe environment for residents.

Complaint Details
The complaint alleged that the facility does not provide a safe environment because the main front door is locked at night and residents cannot exit, and security staff are not always available at the front desk. The allegation was found unsubstantiated.
Findings
The investigation found that the facility's main front door is locked from the outside at night but not from the inside, allowing residents to exit. Residents have key fobs to re-enter, and two side exit doors remain unlocked. Security staff may occasionally be away from the front desk. Based on these findings, the allegation was deemed unsubstantiated.

Report Facts
Facility capacity: 285

Employees mentioned
NameTitleContext
Donna TeutschelEvaluatorConducted telephone interview and complaint investigation
Sondra BrakevilleAdministratorFacility administrator interviewed regarding complaint

Inspection Report

Annual Inspection
Census: 285 Capacity: 285 Deficiencies: 0 Date: Jun 4, 2025

Visit Reason
An unannounced required annual inspection visit was conducted to evaluate the facility's compliance with licensing regulations.

Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met requirements, resident care plans were comprehensive and up-to-date, medication administration followed policies, and health and safety protocols including infection control were properly implemented. Overall, the facility complied with licensing regulations.

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministratorMet with Licensing Program Analyst during inspection and acknowledged receipt of report.
Renita HallLicensing Program AnalystConducted the unannounced required annual inspection.
Denise PowellLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Annual Inspection
Census: 285 Capacity: 285 Deficiencies: 0 Date: Jun 4, 2025

Visit Reason
An unannounced required annual inspection visit was conducted to evaluate the facility's compliance with licensing regulations.

Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met requirements, resident care plans were comprehensive and up-to-date, medication administration followed policies, and health and safety protocols were in place. Overall, the facility complied with licensing regulations.

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministratorMet with Licensing Program Analyst during inspection and acknowledged receipt of report.
Renita HallLicensing Program AnalystConducted the unannounced required annual inspection visit.
Denise PowellLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Follow-Up
Census: 212 Capacity: 285 Deficiencies: 0 Date: Jan 17, 2025

Visit Reason
The visit was an unannounced case management follow-up regarding an incident involving the death of a resident after an unwitnessed fall at the facility.

Findings
The facility followed emergency protocols appropriately, submitted incident reports timely, and maintained safety measures. No deficiencies were cited during this visit.

Report Facts
Resident age: 78 Incident date: Jan 10, 2025 Death date: Jan 13, 2025

Employees mentioned
NameTitleContext
Jessica SwaaleyExecutive DirectorMet with Licensing Program Analyst during the visit
Renita HallLicensing Program AnalystConducted the unannounced case management visit
Denise PowellSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Follow-Up
Census: 212 Capacity: 285 Deficiencies: 0 Date: Jan 17, 2025

Visit Reason
The visit was an unannounced case management follow-up on an incident involving the death of a resident after an unwitnessed fall at the facility.

Findings
The facility acted appropriately and in compliance with applicable regulations regarding the incident. No deficiencies were cited during this visit, and appropriate safety measures were observed.

Report Facts
Resident age: 78 Incident date: Jan 10, 2025 Death report date: Jan 13, 2025

Employees mentioned
NameTitleContext
Renita HallLicensing Program AnalystConducted the unannounced case management visit and interview
Jessica SwaaleyExecutive DirectorMet with Licensing Program Analyst during the visit and discussed the incident
Sondra BrakevilleAdministrator/DirectorInterviewed regarding the incident and facility emergency protocols

Inspection Report

Annual Inspection
Census: 285 Capacity: 285 Deficiencies: 0 Date: Jun 19, 2024

Visit Reason
An unannounced required 1-year annual inspection was conducted to evaluate the facility's compliance with licensing regulations.

Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met requirements, resident care plans were comprehensive and up-to-date, medication administration was compliant, and health and safety protocols including infection control and emergency plans were properly followed. Overall, the facility complied with licensing regulations.

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministratorMet with Licensing Program Analyst during inspection and acknowledged receipt of report.
Renita HallLicensing Program AnalystConducted the unannounced required 1-year annual inspection.
Denise PowellSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Annual Inspection
Census: 285 Capacity: 285 Deficiencies: 0 Date: Jun 19, 2024

Visit Reason
The inspection was an unannounced required 1-year annual visit to evaluate the facility's compliance with licensing regulations.

Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met regulatory requirements, resident care plans were comprehensive and up-to-date, medication administration was compliant, and health and safety protocols including infection control and emergency plans were properly followed. Overall, the facility complied with licensing regulations.

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministratorMet with Licensing Program Analyst during inspection and acknowledged receipt of report.
Renita HallLicensing Program AnalystConducted the unannounced required 1-year annual visit.
Denise PowellLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 220 Capacity: 285 Deficiencies: 0 Date: Mar 30, 2023

Visit Reason
An unannounced complaint investigation was conducted in response to allegations that resident care needs were not being met and that a resident was not given privacy, including claims that a resident's bathroom was locked and inaccessible.

Complaint Details
The complaint was unsubstantiated. Allegations included unmet resident care needs and lack of privacy due to locked bathroom access and residents entering others' rooms. The investigation included interviews and records review, concluding insufficient evidence to substantiate the claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff explained infection control protocols during COVID-19 led to locking a shared bathroom temporarily, and residents in the memory care unit sometimes unintentionally entered other residents' rooms but were redirected by staff.

Report Facts
Capacity: 285 Census: 220 Bathroom locked duration (days): 7

Employees mentioned
NameTitleContext
Carmen LopezLicensing Program AnalystConducted the complaint investigation and delivered findings
Maureen ManzonAssistant Director of Resident CareParticipated in exit interview and received report findings
Severino DoriaDirector of Resident CareParticipated in exit interview and received report findings
Sondra BrakevilleAdministratorConfirmed bathroom locking due to infection control protocols

Inspection Report

Complaint Investigation
Census: 220 Capacity: 285 Deficiencies: 0 Date: Mar 30, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that resident care needs were not being met and that a resident was not given privacy, including a claim that a resident's bathroom was locked and inaccessible.

Complaint Details
The complaint was unsubstantiated. Allegations included resident care needs not being met and lack of privacy due to locked bathroom access. Investigation found protocols in place for infection control and staff assistance. No evidence supported the allegations.
Findings
The investigation included interviews and records review and found that the bathroom was locked due to infection control protocols during a COVID-19 outbreak. Staff assisted residents with bathroom use and sanitization. There was insufficient evidence to substantiate the allegations regarding unmet care needs and lack of privacy.

Report Facts
Capacity: 285 Census: 220 Bathroom locked duration: 7

Employees mentioned
NameTitleContext
Carmen LopezLicensing Program AnalystConducted the complaint investigation and delivered findings
Maureen ManzonAssistant Director of Resident CareParticipated in exit interview and received report findings
Severino DoriaDirector of Resident CareParticipated in exit interview and received report findings
Sondra BrakevilleAdministratorConfirmed bathroom locking due to infection control protocols

Inspection Report

Census: 220 Capacity: 285 Deficiencies: 0 Date: Mar 30, 2023

Visit Reason
Licensing Program Analyst Carmen Lopez conducted a visit to deliver findings for an investigation and to conduct a case management visit.

Findings
No deficiencies were cited during the visit. Technical advisories were given per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

Employees mentioned
NameTitleContext
Maureen ManzonAssistant Director of Resident CareMet during the visit and participated in the exit interview.
Severino DoriaDirector of Resident CareMet during the visit and participated in the exit interview.
Carmen LopezLicensing Program AnalystConducted the visit and delivered findings.
Rebecca HedgecockLicensing Program ManagerNamed in the report as Licensing Program Manager.

Inspection Report

Census: 220 Capacity: 285 Deficiencies: 0 Date: Mar 30, 2023

Visit Reason
Licensing Program Analyst Carmen Lopez conducted a visit to deliver findings for an investigation and to conduct a case management visit.

Findings
No deficiencies were cited during the visit. Technical advisories were given per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

Employees mentioned
NameTitleContext
Maureen ManzonAssistant Director of Resident CareMet during the visit and participated in the exit interview.
Severino DoriaDirector of Resident CareMet during the visit and participated in the exit interview; received report and appeal rights.

Inspection Report

Complaint Investigation
Census: 178 Capacity: 285 Deficiencies: 0 Date: Jan 26, 2023

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not follow the infection control plan, specifically regarding COVID-19 protocols in the memory care unit.

Complaint Details
The complaint alleged that staff did not follow the infection control plan related to COVID-19 protocols in the memory care unit, specifically that COVID-19 positive residents were not quarantined. The allegation was found to be unsubstantiated.
Findings
The investigation included records review, staff interviews, and observations. It was found that memory care residents were quarantined by sections as required, PPE was available, staff had received COVID-19 training, and the facility followed its infection control plan. The allegation was determined to be unsubstantiated.

Report Facts
Facility capacity: 285 Resident census: 178

Employees mentioned
NameTitleContext
Elizabeth HamiltonLicensing Program AnalystConducted the complaint investigation
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during investigation

Inspection Report

Complaint Investigation
Census: 178 Capacity: 285 Deficiencies: 0 Date: Jan 26, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not follow the infection control plan, specifically regarding COVID-19 protocols in the memory care unit.

Complaint Details
The complaint alleged that staff did not follow infection control plan related to COVID-19 positive residents not quarantining in the memory care unit. The allegation was found to be unsubstantiated.
Findings
The investigation found that memory care residents were quarantined by sections as required, staff trainings on COVID-19 protocols were confirmed, and the facility followed its COVID-19 infection control plan. The allegation was found to be unsubstantiated.

Report Facts
Capacity: 285 Census: 178

Employees mentioned
NameTitleContext
Elizabeth HamiltonLicensing Program AnalystConducted the complaint investigation
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during the investigation
Denise PowellLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 217 Capacity: 285 Deficiencies: 1 Date: Jan 12, 2023

Visit Reason
The visit was an unannounced Case Management inspection conducted in response to a self-reported incident on 2022-11-01 where a resident was administered medication to which they were allergic.

Complaint Details
The visit was complaint-related, triggered by a self-reported incident involving a medication error. The report does not explicitly state substantiation status.
Findings
A deficiency was cited for a medication error where Resident 1 was given another resident's medication to which they were allergic, posing an immediate health risk. The facility administrator agreed to conduct medication administration training and provide proof of training by 2023-01-13.

Deficiencies (1)
Incidental Medical & Dental Care Services. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by the administration of another resident's medication to which Resident 1 was allergic, posing an immediate health risk.
Report Facts
Residents in care: 217 Total licensed capacity: 285 Plan of Correction due date: Jan 13, 2023

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministrator/Executive DirectorMet with Licensing Program Analyst during the visit and named in relation to the medication error finding
Kayla HilarioLicensing Program AnalystConducted the unannounced Case Management visit and authored the report
John RanteSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 217 Capacity: 285 Deficiencies: 1 Date: Jan 12, 2023

Visit Reason
The visit was conducted in response to a self-reported incident on 2022-11-01 where a resident was administered medication to which they were allergic.

Complaint Details
The visit was complaint-related due to a self-reported medication error incident involving Resident 1. The deficiency was substantiated and cited.
Findings
A deficiency was cited for a medication error where Resident 1 was given another resident's medication, posing an immediate health risk. The facility staff had current criminal record clearances and residents appeared appropriate for care.

Deficiencies (1)
Incidental Medical & Dental Care Services. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Resident 1 being administered another resident's medication to which they were allergic, posing an immediate health risk.
Report Facts
Residents in care: 217 Total capacity: 285 Deficiency count: 1

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministrator/Executive DirectorMet during the visit and involved in exit interview
Kayla HilarioLicensing Program AnalystConducted the inspection visit
John RanteLicensing Program ManagerSupervisor named in the report

Inspection Report

Census: 219 Capacity: 285 Deficiencies: 0 Date: May 23, 2022

Visit Reason
The visit was an unannounced case management incident review regarding two self-reported incidents involving resident falls and injuries.

Findings
No deficiencies were observed during the visit after touring the facility, interviewing staff, and reviewing records.

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet during visit and discussed purpose of visit.
Diana LopezDirector of Resident CareMet during visit.
Jessica SwaaleyBusiness Office ManagerMet during visit and exit interview.
Vicky WilliamsonLicensing Program AnalystConducted the unannounced case management visit.
Simon JacobSupervisorSupervisor named in report.

Inspection Report

Complaint Investigation
Census: 219 Capacity: 285 Deficiencies: 0 Date: May 23, 2022

Visit Reason
The visit was an unannounced case management inspection regarding two self-reported incidents involving resident falls and injuries submitted to Community Care Licensing.

Complaint Details
The visit was triggered by two incidents: Resident #1 fell and sustained an injury on 2022-05-07 and was hospitalized, returning with hospice care; Resident #2 fell and sustained an injury on 2022-05-13 and was hospitalized. Both incidents were self-reported to Community Care Licensing.
Findings
The Licensing Program Analyst toured the facility, interviewed staff, and reviewed records, finding no deficiencies during the visit.

Employees mentioned
NameTitleContext
Vicky WilliamsonLicensing Program AnalystConducted the unannounced case management visit.
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst to discuss the purpose of the visit.
Jessica SwaaleyBusiness Office ManagerParticipated in exit interview and received a copy of the report.
Diana LopezDirector of Resident CareMet with Licensing Program Analyst during the visit.

Inspection Report

Annual Inspection
Census: 219 Capacity: 285 Deficiencies: 0 Date: May 23, 2022

Visit Reason
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing and infection control requirements.

Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the visit.

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during the inspection and discussed the purpose of the visit.
Diana LopezAssistant Director of Resident CareConducted facility tour with Licensing Program Analyst.
Jessica SwaaleyBusiness Office ManagerParticipated in exit interview and received a copy of the report.

Inspection Report

Annual Inspection
Census: 219 Capacity: 285 Deficiencies: 0 Date: May 23, 2022

Visit Reason
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing and infection control requirements.

Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the visit.

Employees mentioned
NameTitleContext
Sondra BrakevilleAdministrator / Executive DirectorMet with Licensing Program Analyst during the inspection and discussed the purpose of the visit.
Diana LopezAssistant Director of Resident CareConducted facility tour with Licensing Program Analyst.
Jessica SwaaleyBusiness Office ManagerParticipated in exit interview and received a copy of the report.

Inspection Report

Census: 205 Capacity: 285 Deficiencies: 0 Date: Jan 18, 2022

Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's COVID-19 mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).

Findings
During the visit, no deficiencies were cited. The team interviewed the Business Office Manager and conducted a walk-through of the facility, concluding with a debriefing.

Employees mentioned
NameTitleContext
Carmen LopezLicensing Program AnalystConducted the on-site COVID-19 Site Assessment visit.
Jennifer WestCOVID-19 Site Assessment NurseConducted the on-site COVID-19 Site Assessment visit.
Jessica SwaaleyBusiness Office ManagerInterviewed during the visit and participated in the debriefing.

Inspection Report

Census: 205 Capacity: 285 Deficiencies: 0 Date: Jan 18, 2022

Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).

Findings
During the visit, no deficiencies were cited. The team interviewed the Business Office Manager and conducted a walk-through of the facility, concluding with a debriefing.

Employees mentioned
NameTitleContext
Jessica SwaaleyBusiness Office ManagerInterviewed during the visit and involved in debriefing.
Carmen LopezLicensing Program AnalystConducted the on-site HAI assessment visit.
Jennifer WestCOVID-19 Site Assessment NurseConducted the on-site HAI assessment visit.
Rebecca HedgecockLicensing Program ManagerNamed in the report header.

Inspection Report

Annual Inspection
Census: 137 Capacity: 285 Deficiencies: 0 Date: Jun 15, 2021

Visit Reason
Licensing Program Analyst Natasha Persaud conducted an unannounced annual required licensing inspection to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.

Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, with no deficiencies observed during the visit.

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during inspection
Natasha PersaudLicensing Program AnalystConducted the inspection
John RanteSupervisorSupervisor overseeing the inspection

Inspection Report

Census: 137 Capacity: 285 Deficiencies: 0 Date: Jun 15, 2021

Visit Reason
An unannounced case management visit was conducted regarding two incident reports involving resident falls and injuries.

Findings
Both incidents were appropriately addressed by the facility, all required notifications were made, and no deficiencies were issued during the visit.

Report Facts
Incident dates: Incidents occurred on 2021-05-15 and 2021-06-02 Resident death date: Resident #2 passed away on 2021-06-05

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during visit
Dennis PrejusaDirector of Resident CareMet with Licensing Program Analyst during visit
Natasha PersaudLicensing Program AnalystConducted the unannounced case management visit

Inspection Report

Annual Inspection
Census: 137 Capacity: 285 Deficiencies: 0 Date: Jun 15, 2021

Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.

Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, and no deficiencies were observed during the visit.

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet with Licensing Program Analyst during inspection and named in report.
Natasha PersaudLicensing Program AnalystConducted the inspection and authored the report.
John RanteLicensing Program ManagerNamed in report as Licensing Program Manager.

Inspection Report

Census: 137 Capacity: 285 Deficiencies: 0 Date: Jun 15, 2021

Visit Reason
An unannounced case management visit was conducted regarding two incident reports involving resident falls and injuries.

Findings
Both incidents were appropriately addressed by the facility, all required notifications were made, and no deficiencies were issued during the visit.

Report Facts
Incident dates: Incidents occurred on 2021-05-15 and 2021-06-02 Resident census: 137 Facility capacity: 285

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorMet during visit and named in report
Dennis PrejusaDirector of Resident CareMet during visit and named in report
Natasha PersaudLicensing Program AnalystConducted the inspection visit
John RanteLicensing Program ManagerNamed in report

Inspection Report

Census: 150 Capacity: 285 Deficiencies: 0 Date: Jan 22, 2021

Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

Findings
During the visit, no deficiencies were issued. A walk-through of the facility was conducted and a debriefing was held with the Executive Director and Assistant Director.

Employees mentioned
NameTitleContext
Sondra BrakevilleExecutive DirectorInterviewed and participated in the walk-through and debriefing during the visit.
Severino DoriaAssistant DirectorInterviewed and participated in the walk-through and debriefing during the visit.

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