079200975-8-18-2020-15-AS-LIBO-BSLVGW-20200818162614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200975
Report Date: 08/18/2020
Date Signed: 08/18/2020 04:27:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SILVER CREST HOMECARE		FACILITY NUMBER:	079200975
ADMINISTRATOR:	PHLLIPS, TIMOTHY		FACILITY TYPE:	740
ADDRESS:	204 CHAPS COURT		TELEPHONE:	(925) 252-5117
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 0	DATE:	08/18/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Timothy Phillips & Christine Prasad		TIME COMPLETED:	04:30 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	On 08/18/2020 at 10:05 AM, Licensing Program Analysts (LPAs) Leslie Ibo and Luisa Fontanilla made a scheduled visit to this facility for the purpose of completing a Pre-licensing inspection. LPAs met with Applicant Timothy Phillips & Christine Prasad. LPAs observed no residents were present during today’s visit. At 10:15 AM, LPAs toured the entire premises indoors and outdoors. The facility has 5 bedrooms including staff bedroom, 3 bathrooms including staff bathroom, single story house per facility sketch. All 4 bedrooms are designated for residents, one of which is a shared bedroom adjacent to the designated residents’ bathroom. Per administrator, one bathroom located near the kitchen area will be used as common toilet area for residents but will not be used as a shower room for residents. LPAs observed two fire extinguishers one of which was located in the dining area adjacent to the kitchen and another fire extinguisher located at the hallway area near the common bathroom. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 7/28/2020 with an approval for a total capacity of 6 residents all approved for non-ambulatory. LPAs observed a locked cabinet for centrally stored medications in the hallway adjacent to the laundry room. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and 2 days of perishable foods in stock for six people. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 120 degrees Fahrenheit. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at zero degrees Fahrenheit. Continue LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SILVER CREST HOMECARE	FACILITY NUMBER: 079200975
	VISIT DATE: 08/18/2020

NARRATIVE

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Two bedrooms were observed furnished with a bed, bedding, and nightstand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPAs observed the first aid kit was complete with manual. All exit doors in the facility are equipped with auditory signals. Administrator has a pet living at the facility, per Administrator pet is training as a therapy dog with completed vaccines. LPAs verified there is an active telephone line in the facility, which is currently operating.

During today's visit, LPAs reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPAs observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

LPAs conducted component III with Licensee/Administrator.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. However, this report will be submitted to the Central Application Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by the CAB in Sacramento CA. Additional requirements may still be required.

Exit interview conducted with Timothy Phillips and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

LIC809 (FAS) - (06/04)

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