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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802047
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:50:53 PM


Document Has Been Signed on 04/27/2023 01:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SILVA BOARD AND CAREFACILITY NUMBER:
496802047
ADMINISTRATOR:TRINIDAD, JOELFACILITY TYPE:
740
ADDRESS:1130 SILVA AVETELEPHONE:
(707) 542-3500
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 6DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee/Administrator, Joel TrinidadTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Joel Trinidad.

LPA initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 111 and 113 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage.

Fire extinguisher was last inspected June 2022. Facility had a recent fire inspection from the local fire department who tested the combination Smoke/Carbon Monoxide detectors and found no issues. Most recent fire/disaster drill was conducted February, 2023.

Five staff files and five resident files were reviewed. Staff have required First Aid and CPR Certificates and sufficient training hours. Administrator Certificate for Administrator, Joel Trinidad 60022722740 expired 11/22/2022 and is on the Department's pending list. Facility has two backup Administrators with active certificates. Medications and medication records were reviewed. LPA and Licensee discussed needed changes to their Infection Control Plan/Plan of Operation.



Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SILVA BOARD AND CARE
FACILITY NUMBER: 496802047
VISIT DATE: 04/27/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 5/27/2023:
Proof of Liability Insurance
LIC308 Designation of Facility Responsibility (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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