374604526-1-12-2024-08-AS-DCOA-CZF8BU-20240112212255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604526
Report Date: 01/12/2024
Date Signed: 01/12/2024 09:23:26 PM

Document Has Been Signed on 01/12/2024 09:23 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SILVER HEART CHATEAU		FACILITY NUMBER:	374604526
ADMINISTRATOR:	NUCOM, HIDEEN R		FACILITY TYPE:	740
ADDRESS:	9724 EUCALYPTUS CT		TELEPHONE:	(518) 577-3629
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	6	CENSUS: 6	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Caregiver HIlda Rumingan		TIME COMPLETED:	03:45 PM

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1. Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was met by Caregiver Hilda Rumingan, identified herself, was granted entry, and stated the purpose of today’s visit. There were six (6) residents present during today’s visit, all of which were non-ambulatory, and three (3) who received Hospice services. In addition, there were four (4) staff present during today's visit. Licensee Hideen Nucom arrived at the facility and accompanied LPA during the general overall inspection. The facility is licensed to serve 6 residents, age 60 and over, of which all six (6) can be non-ambulatory, as well as all receive Hospice services, and two (2) bedridden.

The facility temperature was 72.7 degrees Fahrenheit at the time of the visit. The resident bathroom's hot water temperature measured between 109.5- and 117.9-degrees Fahrenheit. Disinfectants, cleaning solutions, and poisons were inaccessible to residents. All resident rooms were equipped with the required furnishings. Resident bathrooms were observed to be sanitary and equipped with the required supplies. Showers had grab bars and nonskid flooring. Lighting was maintained in hallways and passages to client bathrooms.

Facility staff provided each resident with clean linen in good repair, padded mattress covers, and sufficient hygiene products for personal use. LPA Correia observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Per Caregiver Rumingan there are no weapons and/or ammunition housed in the facility, nor does the facility have any bodies of water on the premises.

The facility is stocked with a 2-day supply of perishable and 7-day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked cabinet and administered according to the label instructions. The facility's last disaster drill was conducted on November 22, 2023

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVER HEART CHATEAU	FACILITY NUMBER: 374604526
	VISIT DATE: 01/12/2024

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Per staff records reviewed, individuals subject to a criminal record review obtained clearance and/or an exemption; staff responsible for direct care and supervision have current First Aid and CPR training. Licensee Nucom's Administrator Certificate is current until December 2025.

Based on today's visit, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with Licensee Nucom and will be provided with a copy of this report and licensee/appeal rights (LIC 9058 01/16), and their signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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