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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881094
Report Date: 06/04/2021
Date Signed: 06/04/2021 10:25:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A SILVER AMORE SENIOR HOMEFACILITY NUMBER:
331881094
ADMINISTRATOR:DAS, IPSHITAFACILITY TYPE:
740
ADDRESS:12697 BURBANK ROADTELEPHONE:
(310) 985-2314
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 0DATE:
06/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Ipshita DasTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Pauline Beschorner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. LPA arrived at the facility at 9:03 AM and met with Ipshita Das and Shelly Deb. Das took LPA's temperature upon arrival and LPA filled out a COVID questionnaire. Das and Deb accompanied LPA on a tour of the inside and outside of the facility.

Currently there are no residents in care. The home is a four bedroom, three in a half bath home with a living/dining room, activity room, visitor room, and kitchen. Per the approved fire clearance, the licensee is approved for 5 non-ambulatory residents and 1 bedridden resident. All bedrooms are furnished with bed, night stand, dresser and chair and have adequate lighting for residents use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The bathrooms were inspected to have grab bars and non-skid mats installed for resident safety. The water temperature was tested and measured at 113.4 to 119.9 degrees Fahrenheit. The smoke alarms and carbon monoxide alarm were tested and are in operating order. LPA observed fire extinguishers present in the facility and fully charged. The kitchen was observed to have dishes, silverware and pots and pans. The knives were stored in a locked drawer in the kitchen. The medications, were in the locked hall closet. The chemicals are locked in a storage closet in the garage. The client files are locked in the medication closet and staff files are locked and kept in a locked cabinet in the hall. The backyard was observed to be fully fenced with an unlocked gate. The facility does have a jacuzzi that is fenced and locked.

An exit interview was conducted and a copy of this report was reviewed with and provided to Licensee Ipshita Das.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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