<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700133
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:09:41 AM

Document Has Been Signed on 12/13/2021 11:09 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SILVER PINES CARE HOME I LLCFACILITY NUMBER:
342700133
ADMINISTRATOR:LOESCH, DEBBIEFACILITY TYPE:
740
ADDRESS:8625 HUME COURTTELEPHONE:
(916) 686-1936
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
12/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Debbie Loesch TIME COMPLETED:
11:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was met by Administrator Debbie Loesch. Administrator confirm zero residents and staff that have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio reviewed facility file for resident 1. LPA Valerio observed an LIC 602 dated June 2021 and an updated LIC 602 dated 12/08/2021. Resident 1 was admitted to the facility 08/08/21 due to moving out of another licensed facility.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held, a copy of the report was given, and a copy was left with Administrator Debbie Loesch.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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 1