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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700530
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:56:11 AM

Document Has Been Signed on 08/11/2022 10:56 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 II, LLCFACILITY NUMBER:
342700530
ADMINISTRATOR:LOESCH, DEBBIEFACILITY TYPE:
740
ADDRESS:8717 VALLEY OAK LANETELEPHONE:
(916) 308-2968
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Debbie Loesch - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA's) Ruth Wallace and Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's introduced themselves to Administrator and explained the purpose of the visit. LPA's were screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.
 
LPA's and administrator inspected physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA's also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan uploaded into FAS. LPA's observed the facility to have COVID-19 informational signs, social distancing signs, hand washing signs posted throughout the facility. The facility is able to designated and dedicated an isolation area if needed. LPA's observed the temperature inside the facility was measured at 75*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured in kitchen sink at 108.8 *F , which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

LPA's observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers are current and last inspected on 11/15/2021. Backyard was observed to have a large shaded area for visiting and gardening. Backyard was observed to have chickens in a chicken coop. The eggs are not used for resident consumption.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II, LLC
FACILITY NUMBER: 342700530
VISIT DATE: 08/11/2022
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Continued from 809 - Page 2

LPA's reviewed three (4) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.
LPA's reviewed three (3) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA's received updated copies of documentation on today's date: LIC 308 - Designation of Administrator
LIC 610E Emergency Disaster Plan, and Liability Insurance.
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit.

An exit interview was held, and a copy of the report was left with Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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