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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602001
Report Date: 06/22/2022
Date Signed: 06/22/2022 02:55:25 PM


Document Has Been Signed on 06/22/2022 02:55 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SILVER TREE VILLAFACILITY NUMBER:
374602001
ADMINISTRATOR:MOHAMMAD ARABSHAHIFACILITY TYPE:
740
ADDRESS:1592 SILVER TREE LNTELEPHONE:
(760) 739-8393
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Regina Abdelgahni, CaregiverTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Regina Abdelghani and explained the purpose of today's visit. Six (6) of six (6) residents in care were present during today's visit.
During the inspection, LPA observed one central entry point for universal entry screening, routine symptom screening initiated at entry for visitors, a sign-in policy enacted for all visitors, signs posted throughout the facility to promote hand hygiene and physical distancing. LPA observed that the facility was also equipped with sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a plan in place to track all COVID-19 cases and/or suspected cases and that a plan to ensure staff are trained in the facility's infection control measures. The facility also has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated lead person responsible for the monitoring of residents for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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