496802047-5-20-2022-21-AS-VWIS-CELUSJ-20220520155026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802047
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:50:40 PM

Document Has Been Signed on 05/20/2022 03:50 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SILVA BOARD AND CARE		FACILITY NUMBER:	496802047
ADMINISTRATOR:	TRINIDAD, JOEL		FACILITY TYPE:	740
ADDRESS:	1130 SILVA AVE		TELEPHONE:	(707) 542-3500
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 6	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee, Joel Trinidad		TIME COMPLETED:	04:00 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) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Joel Trinidad. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed posters outside with screening question. After entry, Licensee asked LPA to check their temperature on a thermometer attached to the wall and LPA filled out a visitor sign in that included standard Covid-19 screening questions and requests visitors to show proof of vaccination per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 2:00 pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day. Facility maintains documentation of staff and resident daily temperatures. During walk through LPA observed a staff just outside of a large locked hallway closet. Per Licensee, the staff was a live-in. LPA asked Licensee to unlock the door and when they did, LPA observed a mattress on the floor of the closet. Based on discussion with Licensee, the staff previously slept in the designated staff room but when the Licensee moved into the staff room to provide over night care, they moved the staff to the closet. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continues to receive PPE training but have not been N95 fit tested. Per Licensee, they frequently go over donning and doffing of PPE with staff. LPA and Licensee discussed visitation and activities. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SILVA BOARD AND CARE	FACILITY NUMBER: 496802047
	VISIT DATE: 05/20/2022

NARRATIVE

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Continued from LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2021 and Licensee has made an appointment to have them serviced in June 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Infection Control Plan is due June 30, 2022.

Licensee/Administrator to updates of the following by 6/20/2022:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of current Administrator's Certificate
Copy of Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SILVA BOARD AND CARE	FACILITY NUMBER: 496802047
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(a)

87307 Personal Accommodations and Services - (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having a live-in staff sleep in a hallway closet, which poses an immediate risk.
	POC Due Date: 05/21/2022
	Plan of Correction
1 2 3 4	Licensee to remove personal items and bed from the closet and submit a picture of the closet to LPA along with a written statement indicating that areas of the facility not approved for bedrooms by the fire department will not be used as sleeping quarters for staff or residents by POC due date, 5/21/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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