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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701419
Report Date: 10/04/2024
Date Signed: 10/04/2024 12:04:08 PM

Document Has Been Signed on 10/04/2024 12:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SILVER SPRINGS RCFE 1FACILITY NUMBER:
342701419
ADMINISTRATOR/
DIRECTOR:		CHAN, JACQUELINEFACILITY TYPE:
740
ADDRESS:6936 GLORIA DRTELEPHONE:
(601) 273-8064
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:David CaslerTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/4/24 at 9:15am Licensing Program Analyst (LPA) Kevin Gould arrived at Silver Springs RCFE 1 for the purpose of conducting a pre-licensing inspection for a change of ownership. LPA met with Licensee, David Casler and together conducted a tour of the home. There are currently 6 residents in care.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA and Licensee completed Component III orientation.

LPA measured the water temperature, temperature measured at 120 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. The licensee has met all requirements to be licensed. LPA did observe there is currently one (1) resident receiving hospice services and LPA did not observe any documentation of approved hospice care waiver. Please ensure hospice waiver is approved prior to licensing the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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