<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700133
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:01:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/07/2024 12:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SILVER PINES CARE HOME I LLCFACILITY NUMBER:
342700133
ADMINISTRATOR/
DIRECTOR:		LOESCH, DEBBIEFACILITY TYPE:
740
ADDRESS:8625 HUME COURTTELEPHONE:
(916) 686-1936
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Debbie LoeschTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/7/24, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - Annual Continuation visit at the facility to continue with the Annual Required Inspection visit initiated on 10/31/24. LPA initially met with a staff on duty (S1) and stated the purpose of the visit. The Administrator Debbie Loesch was notified of this visit and arrived shortly after with Assistant Administrator Ingrid Myers. Present during today's visit were 6 residents in care with 1 staff on duty (S1).

The LPA continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is fire cleared for 6 non-ambulatory residents.

Review of 4 sample resident files (R1, R2, R3, R4) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. No issues were noted at this time.

Medication review of 2 sample residents (R3 and R5) include review of physician orders for over-the-counter medications. No issues were noted at this time.

Review of 3 sample staff files (S1, S2, and S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator will send updated First Aid/CPR for staff S2, Health Screen for S2 and S3, and associate S2 back to this facility.

Facility conducts monthly disaster drill and last drill was on 10/8/24. Facility has a dementia and infection control plan.

Administrator will also submit updated LIC500 and LIC308 to the Department.
{1 of 2}
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SILVER PINES CARE HOME I LLC
FACILITY NUMBER: 342700133
VISIT DATE: 11/07/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA conducted a case management review of the incident report dated 10/25/24, involving resident R4, in collaboration with the administrator. According to the report, on 10/25/24 at approximately 3:00 AM, R4 fell while attempting to walk to the commode. R4 lost balance and fell backward, resulting in a laceration to the back of the head. The administrator confirmed that the injury was not life-threatening and first aid was promptly administered. Hospice was notified, and a hospice team member arrived the same day to assess the injury and provide additional treatment for R4.

The administrator noted that R4 was not initially considered a fall risk at the time of the incident and had been placed on hospice care on 9/12/24. Following the review, the administrator indicated they will submit an updated fall risk assessment for R4, as well as a Fall Prevention Plan for R4 and other residents identified as fall risks. The updated plans will be submitted by 11/30/24.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during today's visit.

Exit interview was conducted and a copy of the report was provided upon exit.














{2 of 2}
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2