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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701420
Report Date: 10/04/2024
Date Signed: 10/04/2024 04:28:05 PM

Document Has Been Signed on 10/04/2024 04:28 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 2FACILITY NUMBER:
342701420
ADMINISTRATOR/
DIRECTOR:		CHAN, JACQUELINEFACILITY TYPE:
740
ADDRESS:6765 RIVERSIDE BLVDTELEPHONE:
(601) 273-8064
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jackie ChanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 10/4/24 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Silver Springs RCFE 2 for the purpose of conducting a pre-licensing inspection for a change of ownership. LPA met with staff, Jackie Chan and together conducted a tour of the home. There are currently 6 residents in care.

Based on LPA observations this facility is not ready to be licensed.

LPA observed deficiencies with Injections, syringe disposal, reporting requirements and physical plant.

LPA appropriately cited the current licensed facility and have developed plans of correction with the staff member present.

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.

A follow up pre-licensing inspection will be scheduled and follow up inspection will be made to ensure corrections and to ensure facility meets all title 22 regulations.

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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