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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602001
Report Date: 06/16/2023
Date Signed: 06/16/2023 08:02:27 PM


Document Has Been Signed on 06/16/2023 08:02 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
RIVERSIDE AC/SC, 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: 4DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:57 PM
MET WITH:Licensee, Mohammad Arabshahi TIME COMPLETED:
08:10 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced at the above facility to conduct a required annual inspection. LPA was greeted and granted entry by Lead Caregiver Regina Abdelghani. LPA introduced self, and stated the purpose of the visit. Administrator, Mohammad Arabshahi joined shortly to conduct an overall tour of the facility inside and out. Present in the facility during time of visit were four (4) residents and two (2 )staff. Staff interview was conducted and client interviews were conducted.
The facility is a one story six (6) bedroom, six (6) bathroom home. The facility appears clean and free of odors. Resident bedrooms are clean and appropriately furnished, and each have their own bathroom. All smoke and carbon monoxide detectors were tested and found operable. Food supplies are sufficient. Emergency food and water was stored in a storage area. Hot water was measured at 117.6 degrees in the residents bathroom. LPA observed all toxic chemicals and other hazards secured and inaccessible to residents and are centrally stored in a locked laundry room. Furniture in the facility is in good repair. Outdoor space is free of hazards.

LPA inspected staff and client records. Review of staff records indicated all staff have criminal record clearances and are appropriately associated to the facility. Staff files had the required documentation including First Aid Certifications and training documents. LPA inspected medications and medications appear to be dispensed appropriately according to physician's orders. The facility is completing emergency drills regularly. Dues are current.

During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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