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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803538
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:57:07 PM

Document Has Been Signed on 09/21/2022 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SILVER RAIN HOME CAREFACILITY NUMBER:
197803538
ADMINISTRATOR:EUGENE ALANGUIFACILITY TYPE:
740
ADDRESS:1707 SILVER RAIN DR.TELEPHONE:
(909) 861-3438
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Eugene Alangui, AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Eugene Alangui and explained the purpose of the visit. A Dementia and Hospice Waiver is in place. The facility is a single story home licensed for 6 non-ambulatory residents. It consists of 4 resident bedrooms [2 shared & 2 private], 1 staff room, 2 bathrooms, dining room, kitchen, living room, family room, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 9/15/2022. Administrator certificate expires 9/24/2022.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • If needed a designated COVID-19 isolation room will be in place.
  • A posted Emergency Disaster Plan was observed.
  • Centrally stored medications/30-day supply of medications were observed. Today's medications were unlocked in a plastic box container. Photo was taken.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Sharps/knives were observed unlocked under the kitchen sink. Staff immediately locked the cabinet.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • Resident (R1's) bed had full bed rails and is not presently enrolled in hospice. A citation was issued. Licensee was instructed to obtain a physician order for a half bed rail. A new order was obtained today.
Per California Code of Regulations, Title 22, deficiencies were observed. See LIC 809D. Exit interview was conducted with Administrator Eugene Alangui. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/21/2022 03:57 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/21/2022 at 03:23 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVER RAIN HOME CARE
FACILITY NUMBER: 197803538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that residents medications were observed unlocked in a plastic box container (photo taken); which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee shall ensure that caregiver staff always store medications in a locked place. Caregiver staff immediately locked the medications. Submit proof of staff training by tomorrow.

Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that resident (R1's) bed had full rails and the resident is not enrolled in hospice services; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee shall ensure that full bed rails are only placed in beds in which the resident receives hospice services.
Licensee obtained a physician order for half bed rails during today's visit. ***Cleared during the visit.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/21/2022 03:57 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/21/2022 at 03:23 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVER RAIN HOME CARE
FACILITY NUMBER: 197803538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that knives and cleaning supplies were observed unlocked under the kitchen sink; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee shall conduct staff training and submit proof by tomorrow. NOTE: Staff immediately locked the cabinet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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