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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208956
Report Date: 07/20/2022
Date Signed: 07/20/2022 10:41:42 AM

Document Has Been Signed on 07/20/2022 10:41 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SILVER HOUSE ASSISTED LIVINGFACILITY NUMBER:
547208956
ADMINISTRATOR:GARDINER, RACHAELFACILITY TYPE:
740
ADDRESS:4439 W HAROLD AVETELEPHONE:
(559) 936-2891
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: DATE:
07/20/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Licensee Rachael GardinerTIME COMPLETED:
11:00 AM
NARRATIVE
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An informal meeting was held on 07/20/2022 at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting.

The following were in attendance:
Rachael Gardiner, Licensee/Administrator
Becki Winter, Staff (Via Telephone)
Sergiy Pidgirny, Licensing Program Manager
Shawna Doucette, Licensing Program Analyst

Licensee was provided with copies of all applicable regulations and/or Health and Safety Code.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 10:41 AM - It Cannot Be Edited


Created By: Shawna Doucette On 07/20/2022 at 10:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SILVER HOUSE ASSISTED LIVING
FACILITY NUMBER: 547208956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Plan of Correction POC Licensee agrees to come up with a written plan and understanding of this regulation.
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This requirement was not met as evidenced by LIcensee did not call 911 once R1 had a change in condition. Licensee did not call 911 once resident passed and called another staff to respond to the facility prior to calling 911 which poses an immediate health, safety and/or personal rights risk to residents in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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