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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201417
Report Date: 01/10/2022
Date Signed: 01/10/2022 06:31:24 PM

Document Has Been Signed on 01/10/2022 06:31 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SILVERLAKE HOMEFACILITY NUMBER:
157201417
ADMINISTRATOR:NEBRIDA, OFELIAFACILITY TYPE:
740
ADDRESS:3303 SILVERLAKE DRIVETELEPHONE:
(661) 829-5349
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 4CENSUS: 4DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ofelia Nebrida, AdministratorTIME COMPLETED:
02:40 PM
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On 1/10/22, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Administrator (ADM) Ofelia Nebrida arrived a short time later.

LPA toured inside and outside of facility. No obstructions observed. No fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.

The following updated forms to be sent to CCL within 2 weeks:

LIC500, LIC610E (new version), LIC400, LIC402

No deficiencies cited during inspection.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report will be emailed to ADM with "Read receipt" to confirm receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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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