366425833-8-11-2023-56-AS-MMAE-CULUKB-20230811153852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425833
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:39:06 PM

Document Has Been Signed on 08/11/2023 03:39 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 HOMES		FACILITY NUMBER:	366425833
ADMINISTRATOR:	ROLANDO/ZENAIDA SERQUINIA		FACILITY TYPE:	740
ADDRESS:	25117 LAWTON AVENUE		TELEPHONE:	(909) 796-1223
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Rolando Serquinia, Administrator		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Rolando Serquinia, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (5) residents. Hospice waiver for 3. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. Facility has no outdoor bodies of water. Facility has a covered patio area and enclosed with a self-latching back gate. However, facility auditory/alert systems were not functioning properly. Deficiency cited. LPA inspected the kitchen. The refrigerator temperature is maintained at 39 degrees F. Hot water temperature is maintained at 107 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. Facility has sufficient cups, plates, and utensils for resident use. LPA did observed the vent above the kitchen stove was soiled with grease and debris. Deficiency cited. LPA inspected resident bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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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: 08/11/2023

NARRATIVE

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LPA inspected client bathrooms. Bathrooms are equipped with handrails and operating in safe and sanitary conditions. The hot water temperatures in bathrooms tested between 105 to 107 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Facility has operating telephone service on the premises. Posters such as personal rights, complaint telephone number, emergency phone numbers are posted in a common area. Emergency drill conducted on 8/4/23. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed.

All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings training certifications, employee rights and personnel records.

LPA reviewed three (3) resident records for admissions agreements, physician's reports, personal rights: residential care for the elderly, record of safeguarded cash resources. LPA observed resident #2 (R2) last medical assessment was in 2019, due to R2's medical condition an annual assessment is required. Deficiency cited.

Deficiencies were cited during today's visit and a plan of correction was discussed with the Administrator.

An exit interview was conducted, where reports (LIC809 & LIC809-D) were discussed and a copy of the reports with appeal rights was provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2023 03:39 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by alert features not working properly as required for cared of Dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2023
	Plan of Correction
1 2 3 4	Administrator had disabled alert system on doors. Administrator fixed and tested the alert systems during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/11/2023 03:39 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above as observed the vent above the kitchen stove is soiled with grease and debris, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Administrator to provide proof cleaned stove vent submit to the licensing agency by POC date

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above by resident #2 (R2) last medical assessment was in 2019, due to R2's medical condition an annual assessment is required, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2023
	Plan of Correction
1 2 3 4	Administrator to provide proof of medical assessment by resident's physician to the licensing agency by POC date

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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