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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427244
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:18:14 PM


Document Has Been Signed on 11/22/2023 03:18 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SILVER LIVING HOME CAREFACILITY NUMBER:
336427244
ADMINISTRATOR:CANDIDATO, FLORINAFACILITY TYPE:
740
ADDRESS:22590 TEMCO STTELEPHONE:
(951) 563-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 4DATE:
11/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Adella Tolentino, Caregiver TIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to follow up on complaint #18-AS-20230523095508. LPA identified himself, and was granted entry by Caregiver Juanita Mallari.

During this visit, LPA toured the facility, conducted interviews with staff, and residents, and made observations related to a statement provided during complaint #18-AS-20230523095508.

LPA observed a "sliding lock" above the front door keeping it secure, in addition to a standard door lock that was present and functional. Staff indicated that the additional lock was to prevent intruders. Staff stated that at some point in the past, potential intruders attempted to kick the door in, and a lock was placed for added security. LPA witnessed a small crack running the length of the door, as a result of the incident as stated by staff. Record review indicated that there is one bedridden resident as well as two non-ambulatory residents. The facility was cited per Title 22.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC809D, and Appeal Rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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)
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Document Has Been Signed on 11/22/2023 03:18 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SILVER LIVING HOME CARE
FACILITY NUMBER: 336427244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
87468.1(a)(6)

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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not being met as evidenced by:
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Licensee agrees to remove the lock, and to conduct in-service training on the cited regulation and provide proof of such by POC date.
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Based on observation, and staff interview, the sliding lock prevents the residents from leaving the facility. This presents a potential personal rights violation to residents in care.
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
LIC809 (FAS) - (06/04)
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