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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803499
Report Date: 05/21/2024
Date Signed: 05/21/2024 10:45:32 AM

Document Has Been Signed on 05/21/2024 10:45 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SILVER STARFACILITY NUMBER:
496803499
ADMINISTRATOR/
DIRECTOR:		KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1966 DENNIS LANETELEPHONE:
(707) 595-3605
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Ami Kumar (Licensee)TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual required inspection and met with Licensee Ami Kumar and Janine Sorenson, facility Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents.

LPA/staff initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Two fire extinguisher was last serviced December 2023. Carbon monoxide and smoke alarms are hard wired with sprinklers and fire door in the hallway were tested and operational at time of inspection. Last Disaster drill was conducted on 4/12/24. Working auditory alarms are placed on all exits and they were operational. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Medications were centrally stored and locked. Hot water temperature reading was 105.3 degrees which is within regulation.

LPA initiated file review at 9:30 am. LPA reviewed six residents files and four staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training. Administrator Certificate for Ami Kumar, 6021684740, expires on 11/8/24. Medications and medication records were reviewed. LPA had a conversation with Licensee regarding start dates should not be written on the prescription label. Licensee agreed to review and update them if needed.

Licensee agreed to submit updates of the following documents by 5/27/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of Liability Insurance.
No deficiencies cited during today's inspection.
Exit interview was conducted with Licensee and a copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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