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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881094
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:41:49 PM


Document Has Been Signed on 06/14/2023 02:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
06/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Farrah Pena, CaregiverTIME COMPLETED:
02:50 PM
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During the course of a complaint investigation visit conducted on 05/23/2023, LPA Anna Bueno observed four VTech audio baby monitors on the low table in the corner of the room. LPA observed the baby monitor with a white front face and yellow trim two of the four units had green lights on, indicating that they were on. LPA asked administrator Shelly Dab what the audio baby monitors were used and Dab stated that this was used as a signal device so that the caregiver can hear the residents when they ask for help. LPA informed Dab that the device violates the resident's privacy because only the parent/control unit has the option to be muted. LPA explained to Dab that when residents are engaged in private conversation, the listening/baby unit captures all sounds.

LPA Amy Goldenberg is conducting a visit on this date to follow up that baby monitors have been removed from the bedrooms. LPA met with Farrah Pena, Caregiver. LPA observed the baby monitors on and in place in the residents bedrooms. LPA informed the caregiver to remove the baby monitor devices as they violate the personal rights of the residents in care. Baby monitors were removed and the regulatory violation was reviewed with the caregiver.

LPA Amy Goldenberg reviewed LIC 809, 809D, LIC 9098 and appeal rights with Farrah Pena, Caregiver. A copy of these items were provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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Document Has Been Signed on 06/14/2023 02:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: A SILVER AMORE SENIOR HOME
FACILITY NUMBER: 331881094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2023
Section Cited
CCR
87468.2(a)(1)

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... To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Baby monitors were removed from the resident bedrooms and stored in the garage during this visit abating the violation. Licensee to review regulation on personal rights 87468.1, all sections and submit LIC 9098 self certifying that the regulation was reviewed and understood.
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 The facility has not met this mandate as evidenced by the presence of baby monitors in resident bedrooms which do not allow residents to have privte conversations at any time.
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If the licensee has any questions with regulation interpretation they will reach out to an LPA for guidance at anytime.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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