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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530174
Report Date: 11/22/2023
Date Signed: 11/22/2023 10:39:17 AM


Document Has Been Signed on 11/22/2023 10:39 AM - 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:SILVER AMORE SENIOR HOME, AFACILITY NUMBER:
335530174
ADMINISTRATOR:AQUINO, MICHAELFACILITY TYPE:
740
ADDRESS:12697 BURBANK ROADTELEPHONE:
(562) 702-6922
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 4DATE:
11/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lea Aquino, Caregiver
Michael Aquino, Applicant/Admistrator		TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 08/24/2023 for a total capacity of 4 ambulatory and two non-ambulatory residents. Fire Clearance was granted 10/11/2023. LPA Goldenberg observed the following:

Structure: Facility was a single story house with four (4) resident bedrooms, four bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems are operational.

Bedrooms: Each resident bedroom will accommodate non-ambulatory residents. Bedroom #4 cleared for bedridden. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured and adjusted to regulatory parameters of 105-120 degrees F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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 2


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: SILVER AMORE SENIOR HOME, A
FACILITY NUMBER: 335530174
VISIT DATE: 11/22/2023
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Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no accessible bodies of water observed. There is an jacuzzi surrounded by a safety fence and cover which is empty of water.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted.

General items: Smoke detectors were tested and operational. LPA observed a facility phone and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time.

LPA Goldenberg reviewed this report and provided a copy to Michael Aquino.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2