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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700530
Report Date: 07/16/2024
Date Signed: 08/22/2024 02:16:08 PM


Document Has Been Signed on 08/22/2024 02:16 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Debbie LoeschTIME COMPLETED:
12:50 PM
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On 7/16/24, at 10am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required visit. LPA met with Debbie Loesch, Administrator (ADM), and explained the purpose of the visit. During this visit, present were 5 residents in care and 6 staff.

The facility is a one-story home located in a residential neighborhood. LPA and ADM 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. LPA observed a covered patio with outdoor furniture. Fences and gate were observed to be in good repair. Hot water temperature was measured at 109*F. Room temperature was observed at 75*F. Carbon monoxide and smoke detectors were observed and tested and found to be operable. Food supplies were observed to be properly stored. Facility maintains 2-day perishable and 7-day nonperishable food supplies. Oxygen signage was observed. Fireplace was observed to be screened and not in use.

Today was the facility's grocery day. Staff were observed to be completing ADLs, assisting residents, and preparing lunch. Residents were observed watching TV, and some were inside their room watching television.

LPA reviewed 5 staff files and 5 resident files. Technical assistance (TA) was provided to complete ongoing training and ensure all required staff files are maintained. For resident files, TA was provided to ensure facility maintains a complete resident files including updating Needs and Services Plan, ensuring signatures were completed, and PRN authorization to be obtain for each resident, medical assessment of ambulatory status is accurate. LPA reviewed 2 of 6 residents medications. Per review of disaster procedure, facility conducts monthly fire drills. No health or safety concerns were observed during this visit.

LPA requested a copy of the following documents to be emailed by 7/18/24: updated LIC500, LIC308 and current Liability Insurance Certificate.

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) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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