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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700133
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:39:19 AM


Document Has Been Signed on 09/28/2023 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, 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:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Debbie LoeschTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Christina Valerio and Policy Analyst (PA) Melody Bradley arrived to the facility unannounced to conduct an annual required inspection. LPA met with Licensee/Administrator Debbie Loesch, and explained the purpose of the visit.

LPA Valerio, PA Bradley, and Licensee Debbie Loesch toured the physical plant to ensure compliance of Title 22 regulations. LPA Valerio observed resident bedrooms. Resident bedrooms were fully furnished and free from odors. Resident bathrooms were fully stocked with paper towels, toilet paper, handrails, skid mats, soap, and hand sanitizer. Hot water was measured at 106.3*degrees F. The temperature inside the home was 73*F. Common areas were observed to be clean, organized, and free from debris. LPA observed central heating and air, fully charged fire extinguisher, and first aid kit. The facility had a adequate supply of food to meet the requirements of two days of perishables and seven days of non-perishables. An emergency supply of food and water were observed in the garage. Medications, cleaning supplies, and toxins were observed to be locked away and inaccessible to residents in care. The facility has a backyard with a large outdoor sitting areas for visits, has pet goats that are secured behind a locked fence, a place for gardening, and 2 sheds. The sheds were observed to be used for storage. No health or safety concerns observed.

LPA reviewed 3 staff files. Staff files were observed to be up to date with current training. LPA review 3 resident files. Resident files were up to date with required documents. Residents were observed in their room, eating breakfast, and watching television. Staff were observed fixing breakfast, assisting residents, and completing chores

LPA requested the following documentation: LIC 500, LIC 308, Liability Insurance, and LIC 610D

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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