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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803499
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:50:57 PM

Document Has Been Signed on 03/28/2022 12:50 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SILVER STARFACILITY NUMBER:
496803499
ADMINISTRATOR:KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1966 DENNIS LANETELEPHONE:
(707) 595-3605
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Ami Kumar-AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Dina Alviso, arrived unannounced to conduct a Required 1 -Year inspection and met with Licensee/Administrator Ami Kumar. The inspection is focused on the Infection Control procedures and practices of this facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Mitigation plan was reviewed by the Department. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. Fire extinguishers were serviced and tagged as required- dated 2/18/2022.
There were 5 residents in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry from tje backyard cement patio area; Temperatures are taken, and screening questions are to be answered before being allowed into the facility, all information is logged. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. Medications were stored locked making them inaccessible to residents and care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. LPA observed all staff, including the Administrator to have masks on as required. There was a sufficient supply of food, cleaners, hygiene products, and paper products for use as required.
No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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