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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700530
Report Date: 08/07/2023
Date Signed: 08/07/2023 11:18:51 AM


Document Has Been Signed on 08/07/2023 11:18 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: 4DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Debbie LoeschTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with facility staff, and explained the purpose of the visit. Administrator Debbie Loesch arrived shortly after LPA's arrival.

LPA observed 3 staff on shift. LPA toured the facility to ensure compliance with Tile 22 regulations. LPA observed 5 resident bedrooms. Bedrooms were equipped with a bed, chair, lamp, dresser, and closet space. No emergency exits were obstructed. Resident bathrooms were observed to be clean and had required items. Medications, sharps, and cleaning supplies were observed to be locked and inaccessible to residents in care. Common areas were clean and free from debris.

Staff were observed to be completing ADLs, assisting residents, and preparing lunch. Residents were observed watching a movie, inside their room eating breakfast while watching television, and doing activities with the Activity Director. Breakfast today was pancakes, eggs, bacon, fruit, and drinks. Lunch today will be tuna salad sandwiches with eggs and Jello.

LPA reviewed 3 staff files and 3 resident files. LPA observed staff files to be complete with required training and documents. Resident files were observed to have complete assessments, care plans, and required documents. No health or safety concerns.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies were observed. An exit interview was held, and a copy of the report was provided
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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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