374604071-7-23-2023-18-AS-CGOH-CU26J9-20230723205047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604071
Report Date: 07/21/2023
Date Signed: 07/23/2023 08:53:06 PM

Document Has Been Signed on 07/23/2023 08:53 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 OAKS COUNTRY ESTATES I		FACILITY NUMBER:	374604071
ADMINISTRATOR:	ECKERT, LORENA		FACILITY TYPE:	740
ADDRESS:	138 SUN VILLA COURT		TELEPHONE:	(760) 415-8216
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 6	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Sarah McKenzie		TIME COMPLETED:	03:58 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) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the Director of Patient Services Sarah McKenzie at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility follows California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents. The Administrator, Dr. Henry Showah arrived later. Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; facility temperature read at 74 degrees; residents' main restroom water temperature read at 110.0 degrees; there were no bodies of water on premises. There are 6 private bedrooms and six bathrooms for the residents. There is one bedroom for staff. There was sufficient lighting and mattress pads in all the residents' bedrooms. The fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds. Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. There is emergency food supply available for all residents and staff. The emergency food supply is located in the garage and a shed in the back yard at 143 Sun Villa Court, Vista, CA 92084, the third facility located next door.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SILVER OAKS COUNTRY ESTATES I	FACILITY NUMBER: 374604071
	VISIT DATE: 07/21/2023

NARRATIVE

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Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. The Administrator has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Waivers are in place and meet said terms. Administrator handles no resident cash resources. The Administrator Certificate for Dr. Henry Showah will expire on 04/23/2024
Summary: Based on today's visit, not deficiencies were cited. An exit interview was conducted with Director of Patient Services Sarah McKenzie and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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