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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604526
Report Date: 01/12/2022
Date Signed: 01/13/2022 07:53:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SILVER HEART CHATEAUFACILITY NUMBER:
374604526
ADMINISTRATOR:NUCOM, HIDEEN RFACILITY TYPE:
740
ADDRESS:9724 EUCALYPTUS CTTELEPHONE:
(518) 577-3629
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 3DATE:
01/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Applicant, Hideen NucomTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Debbie Correia visited the facility to conduct a Pre-licensing inspection and a review of Component III. LPA Correia was met by Applicant Hideen Nucom, identified herself and was granted entry into the facility. Upon facility entry LPA Correia explained the purpose of the visit.

During today's visit, LPA Correia, accompanied by Applicant Nucom, toured the facility and verified compliance with infection control practices. LPA and Applicant Nucom the reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Applicant Nucom and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to her via email. An electronic receipt of confirmation was requested to be sent by the Applicant upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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