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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700236
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:29:17 PM


Document Has Been Signed on 05/05/2023 01:29 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephanie MassothTIME COMPLETED:
02:05 PM
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On 5/5/2023, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required 1-Year Annual inspection. LPA met with caregiver, Odalis Amezcua, who contacted Administrator, Stephanie Massoth, who arrived shortly to the facility. LPA explained to Administrator the purpose of the visit.

Facility has 5 residents, 3 residents on hospice services. Facility is licensed for capacity of 6, hospice waiver of 6.

LPA and Administrator toured the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: common areas, kitchen, laundry room, bathrooms, residents bedroom, and backyard. LPA observed the facility to have two (2) caregivers present. LPA observed facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA observed three (3) residents having lunch, being excited about their Cinco de Mayo meal. LPA observed (2) residents laying down in their room. No health and safety or personal rights violation was observed.

During today's visit, LPA provided Administrator a copy of the Hospice Waiver Approval letter, Bedridden Clearance Approval letter and a new copy of the current license.

LPA was provided a copy of LIC 500, Administrator Certificate, and liability insurance. LPA and Administrator completed the full CARE tool and the facility was found to be in compliance. As a result of todays inspection, observations, and interviews, no deficiencies were observed or cited.

Exit interview conducted and a copy of the report provided to the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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