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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700236
Report Date: 05/19/2022
Date Signed: 05/19/2022 05:08:05 PM


Document Has Been Signed on 05/19/2022 05:08 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SILVER OAKS SENIOR LIVINGFACILITY NUMBER:
342700236
ADMINISTRATOR:MASSOTH, STEPHANIEFACILITY TYPE:
740
ADDRESS:2517 GUNN ROADTELEPHONE:
(916) 764-8628
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Stephanie Massoth, Administrator TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregivers, Alejandra Dominguez and Dallas Amezcua, who contacted Administrator, by phone. Administrator, Stephanie Massoth, arrived at approximately 3:00- pm. LPA observed caregivers, to be wearing masks. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed (3) residents in the common area watching television and (2) residents to be in their rooms. There are currently (3) residents on hospice services.

LPA and caregiver, Alejandra, toured the interior and exterior of the facility, including (6) resident bedrooms, (2) bathrooms, common areas, kitchen, laundry area, office area and garage. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 72* F. Fire extinguishers last serviced 04/12/2022. LPA observed locked medications and sharps in the kitchen and locked toxins in the laundry area. LPA's observed sufficient 2+day perishable/7+day non-perishable food. First aid kits on site. Exit doors and windows have alarms. LPA observed paper towels, soap, sanitizer, and hand-washing posters, trash cans with a lid in the bathrooms. LPA observed sufficient PPE supply and incontinent products. There is (1) outside gate that is unlocked from the inside. LPA observed various Covid posters throughout as well as other required postings. Discussed vaccination status of residents and staff with Administrator and observed facility to be maintaining records of visitor and staff vaccination status. Discussed scheduling a second booster shot with families of residents. LPA observed art supplies, exercise, puzzles, reading materials and pet therapy (2 cats) on file.

Administrator provided a LIC500 and LIC9020 on 5/12/202. LPA obtained copy current of liability insurance. Administrator to follow up on pending RCFE recertification.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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