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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700133
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:43:15 PM


Document Has Been Signed on 06/23/2022 02:43 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SILVER PINES CARE HOME I LLCFACILITY NUMBER:
342700133
ADMINISTRATOR:LOESCH, DEBBIEFACILITY TYPE:
740
ADDRESS:8625 HUME COURTTELEPHONE:
(916) 686-1936
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
06/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Debbie Loesch, AdministratorTIME COMPLETED:
02:50 PM
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On 06/23/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 06/22/2022. LPA spoke with Administrator, Debbie Loesch and explained the purpose of the visit.

Based on incident report, Resident #1 (R1) returned to the facility on 06/15/2022, less then 24 hours later was sent to the Emergency Department. R1 was found with blood in her depends. R1 was not at baseline. Administrator informed R1's family member. R1 passed away on 06/16/2022.

Based on interview with Administrator, R1 was taken to the hospital on 05/21/2022 regarding a fall. R1 stated she was sent to a Skilled Nursing Facility (SNF) for rehab following the hospital visit on 05/21/2022. Administrator stated, R1 returned to the facility the afternoon of 06/15/2022 from SNF. R1 was sent to the hospital the morning of 06/16/2022 due to bleeding in R1's depends. Based on documentation,R1 was admitted to the hospital on 05/21/2022 and was discharged from SNF on 06/15/2022.

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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