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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425833
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:27:18 PM


Document Has Been Signed on 08/19/2024 03:27 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SILVERCARE HOMESFACILITY NUMBER:
366425833
ADMINISTRATOR:ROLANDO/ZENAIDA SERQUINIAFACILITY TYPE:
740
ADDRESS:25117 LAWTON AVENUETELEPHONE:
(909) 435-1644
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 4DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rolando SerquiniaTIME COMPLETED:
03:31 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Becky Mann made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Administrator, Rolando Serquinia, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (4) residents in care. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: Outdoor passageways were not free of obstruction. LPA was not able to clearly walk to the side of the house without brushing against Lime tree. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. Resident bathroom equipment was operating in a safe and sanitary condition. The hot water temperature in bathrooms measured 109 degrees F. Resident bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and sufficient lighting. Facility has operating carbon monoxide alarms, signal system, and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. Sharps, disinfectants, and cleaning solutions were kept locked. The facility has an emergency disaster plan, current disaster drill, and facility insurance on file. The facility has posted in a common area Ombudsman poster, Community Care Licensing Poster, Emergency evacuation sketch, and emergency telephone numbers. The facility has 24-hour, 7 days a week care staff.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Facility's refrigerator has sufficient food storage space.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SILVERCARE HOMES
FACILITY NUMBER: 366425833
VISIT DATE: 08/19/2024
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Health Related Services: LPAs review of medications reveals medications are centrally stored in a locked cabinet and a record of resident medications is maintained at the facility.

Personnel/Resident Records: The Administrator’s certification is current. Staff records were reviewed for health screenings, criminal record clearances/exemptions, first aid/CPR training certification, and training. Resident files were reviewed for emergency contacts, Admission Agreements, appraisals, medication assessments and plans.



Based on observations and record review, a deficiency and a technical advisory was cited per Title 22, of The California Code of Regulations.

An exit interview was conducted where this report and a plan of correction were discussed. A copy of this report was provided with Appeal Rights to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/19/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SILVERCARE HOMES
FACILITY NUMBER: 366425833

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accomodations (d)The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by LPA was not able to clearly walk through passageway leading to the side of the home without brushing against a lime tree; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency proof of cleared passageway by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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