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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700236
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:53:51 PM


Document Has Been Signed on 05/08/2024 03:53 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Yesenia Herrera and Stephanie MassothTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with caregiver and explained the purpose of the visit. Administrator then arrived to the facility after tour was completed.

Today's census is five residents in care with three residents on hospice services. Facility is licensed for five non-ambulatory and one bedridden, hospice waiver of six. LPA observed two residents in the common area, one resident in private room, and two were with visitors in their room.

During today's inspection, LPA and Caregiver conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. LPA and Caregiver conducted a tour of bathroom, laundry, kitchen, resident bedrooms, office, backyard and the common areas. LPA observed sharps in the kitchen to be locked and secured. LPA observed medications to be organized in individual bins locked in the kitchen. LPA observed toxins to be locked separately from other items. LPA inspected the pantry and observed approximately seven days of non-perishable foods. LPA observed refrigerator to be at 40* and presence of approximately two days of perishable foods. LPA observed areas to be clean and free of obstructions.

LPA observed facility to be playing bingo with residents in care. LPA observed the presence of multiple outside agencies. LPA completed file review.

At this time, LPA obtained a copy of facility's liability insurance and Administrator Certificate. LPA is requesting LIC 308 and LIC 500 to be sent to LPA via email.

No deficiencies cited.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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