Community Care Licensing

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) -341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: 559-470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Document Has Been Signed on 08/07/2023 04:52 PM - It Cannot Be Edited

FACILITY NAME: SILVER HOUSE ASSISTED LIVING	FACILITY NUMBER: 547208956
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Fire extinguisher last serviced on 6/3/21, which poses an immediate safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of fire extinguisher serviced, to CCL by POC due date.

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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. A bottle of toilet cleaner observed accessible in bathrooms 1 and 3; cabinet where all chemicals and cleaners are stored was accessible and stored in accessible laundry room; and various paint can sizes observed accessible in open cabinet in accessible garage, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of cabinet where cleaners/chemicals are kept in the laundry room to have a working lock and the door that leads to the garage from the laundry room will have a new lock where a key is to be used to access the garage, to CCL by POC due date.

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Document Has Been Signed on 08/07/2023 04:52 PM - It Cannot Be Edited

FACILITY NAME: SILVER HOUSE ASSISTED LIVING	FACILITY NUMBER: 547208956
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Type A

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. S1 did not have a completed transfer of criminal record clearance and has been working in the facility since 6/28/21, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	Licensee submitted form LIC9182 to LPA. LPA was able to complete a transfer of criminal record clearance for S1 during the inspection. Licensee will submit proof of a written plan about what steps will be taken to ensure new staff have completed transfers of criminal record clearance prior to having the new staff work in the facility, to CCL by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Document Has Been Signed on 08/07/2023 04:52 PM - It Cannot Be Edited

FACILITY NAME: SILVER HOUSE ASSISTED LIVING	FACILITY NUMBER: 547208956
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Type B

Section Cited

CCR

87307(c)

(c) Individual privacy shall be provided in all toilet, bath and shower areas. 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. Bathroom #2 observed with curtain in doorway and door missing, which poses a potential safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of a new door installed for bathroom #2, to CCL by POC due date.

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. R2 does not have TB results and was admitted to the facility on 7/24/23, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of TB results for R2 to CCL by POC due date.

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Document Has Been Signed on 08/07/2023 04:52 PM - It Cannot Be Edited

FACILITY NAME: SILVER HOUSE ASSISTED LIVING	FACILITY NUMBER: 547208956
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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. Residents' medications were observed prepared in advance of five days in a separate week pill box located in the inaccessible kitchen drawer where sharps are stored, which poses a potential health or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of a written statement stating residents' medications will be pre-poured the night prior for the next day's medication administration and will be kept in the file cabinet where medications are centrally stored, to CCL by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

FACILITY NAME: SILVER HOUSE ASSISTED LIVING	FACILITY NUMBER: 547208956
	VISIT DATE: 08/07/2023