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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800609
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:00:25 PM


Document Has Been Signed on 02/24/2023 12:00 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SILVER HILLS RCFEFACILITY NUMBER:
425800609
ADMINISTRATOR:ALAN SEPULVEDAFACILITY TYPE:
740
ADDRESS:501 GARNET WAYTELEPHONE:
(805) 878-9056
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Allan Supulveda / LicenseeTIME COMPLETED:
12:01 PM
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 At 10:00am on 02/24/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual, infection control inspection. LPA met with Licensee Allan Sepulveda and announced who he was and the reason for the visit. Licensee and LPA reviewed facility clearance roster and confirmed all staff working were on the facility roster and all cleared.
Licensee and LPA conducted a cursory tour of the facility. This facility is a seven bedroom, 4.5 bathroom with kitchen, two living rooms and dining room. There is a large center courtyard with a pergola that provided shade for residents. Six of the bedrooms are single occupancy resident rooms, the other bedroom is for live-in staff. Three bathrooms are Jack and Jill style bathrooms that attached to two resident rooms each. LPA observed that all bath rooms were stocked with liquid soap and paper towels. LPA observed at least a 30 day supply of incontinence supplies and more than 30 day supply of PPE located in the garage. LPA observed each resident room and all rooms are in compliance with regulation standards with appropriate bedding, lighting, drawee's and storage. LPA noted that each room had its own exit and all exits were free and clear of obstructions and hazards. LPA noted that each room and hallway had hard wired fire detectors and were functioning properly, additionally Licensee installed a new carbon monoxide detector the day of this inspection. LPA observed a fire extinguisher that was charged in the green. LPA observed at least 2 days of perishable and at least seven days of non-perishable foods. LPA tested facility water temperature and noted that it was within regulation parameters of 105*-120P(f). LAP did not observe any violations, technical or citations during the cursory walk through tour of the facility.
Licensee and LPA conducted the annual infection control module of the annual inspection tool. LPA Licensee on Provider Information Notice (PIN)'s postings and new PIN's released that pertained to infection control.. LPA noted that no violations, technical, or citations were discovered as a result of the infection control module of the annual inspection. LPA noted that no violations, technical, or citations were issued during this infection control, annual inspection at this time.
Exit interview, report singed, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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