<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803538
Report Date: 09/19/2023
Date Signed: 09/19/2023 04:05:28 PM


Document Has Been Signed on 09/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SILVER RAIN HOME CAREFACILITY NUMBER:
197803538
ADMINISTRATOR:EUGENE ALANGUIFACILITY TYPE:
740
ADDRESS:1707 SILVER RAIN DR.TELEPHONE:
(909) 861-3438
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Emelita Alangui, Co-AdministratorTIME COMPLETED:
04:15 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
Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Co-Administrator, Emelita Alangui, who assisted with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, and there is an approved hospice waiver.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility staff are using appropriate hand hygiene and wearing gloves while assisting residents with some of the activities of daily living. Facility has sufficient PPE supplies. Licensee has submitted an Infection Control Plan.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility. The facility has maintained the sufficient amount for liability insurance covering injury to residents and guests.
Physical Plant & Environment Safety: The facility has 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, dining/family room, kitchen, and attached garage. There is no swimming pool on the premises. Facility has operable smoke and carbon monoxide combo detectors. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. The kitchen is kept clean and free of insects.

There are no deficiencies issued today. LPA will return another day to complete the rest of the inspection. An exit interview was held and a copy of this report was given to Emelita Alangui.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1