336427244-10-18-2024-18-AS-AZEO-DA6U5C-20241018151630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427244
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:16:44 PM

Document Has Been Signed on 10/18/2024 03:16 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 CARE		FACILITY NUMBER:	336427244
ADMINISTRATOR:	CANDIDATO, FLORINA		FACILITY TYPE:	740
ADDRESS:	22590 TEMCO ST		TELEPHONE:	(951) 563-0181
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Adela Tolentino		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Sara Martinez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by caregiver Adela Tolentino, notified of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Administrator Candidato Florina joined at a later time and was informed of the reason of the visit.

Facility Overview: The facility is a single story building with 4 residents bedrooms, 1 staff bedroom and 2 bathrooms. There is gated pool meeting the department's requirements and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet under the sink and inaccessible to residents. The smoke detector and carbon monoxide detector were working and operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 06/28/2025. LPAs observed the hot water temperature to meet requirements at 108.7°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Continued on LIC809-C.....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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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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
	VISIT DATE: 10/18/2024

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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of May 17^th, 2025.

Record Review and Resident/Staff Files: LPAs reviewed files for three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five residents' files were reviewed and contained all required documentation. LPA's observed Staff, resident files, were stored in locked cabinet next to the dining area. PPE's and water were stored in the garage and the first aid kit was hanged in the dining area.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked and located in the dining area. LPAs reviewed medications for five residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. LPAs observed resident's medication in a refrigerator with perishable food located in the garage that is accessible to residents in care. A citation will be issued.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-03-2024, which met department requirements. LPAs observed both gates to be locked. A citation will be issued.

An exit interview was conducted and a copy of this report was provided to administrator Florina Candidato along with the appeal rights

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 03:16 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: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(1)(A)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 medication stored in a fridge in the garage, accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Caregiver removed the medication from the fridge and properly disposed it. Licensee will conduct staff training regarding the proper procedure for disposing medication. Licensee will submit proof of training to LPA by the plan of correction date

Type B

Section Cited

CCR

87468.1(a)(6)

87468.1 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 gates observed to be locked, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Licensee removed all locks from the gates. licensee will conduct training regarding residents' personal right and submit proof of training to LPA by the plan of correction date

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 Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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