312700882-11-10-2020-27-AS-KLEL-BV8TGC-20201110134256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700882
Report Date: 11/10/2020
Date Signed: 11/10/2020 01:44:05 PM

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:	SPLENDOR OAKS SENIOR LIVING #4		FACILITY NUMBER:	312700882
ADMINISTRATOR:	LEE, KEVIN		FACILITY TYPE:	740
ADDRESS:	6905 POCA MONTOYA DR		TELEPHONE:	(412) 608-2690
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 5	DATE:	11/10/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Kevin Lee (Administrator)		TIME COMPLETED:	12:00 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 Analysts (LPA) Konnor Leitzell conducted a scheduled pre-licensing inspection via tele-visit on 11/10/2020. Due to COVID-19 and precautionary measures, this inspection was done over FaceTime. This is a change in ownership there are currently four (4) resident at the facility. LPA and Administrator toured the interior and exterior of the facility, viewing the common areas, residents bedrooms, bathroom, kitchen. LPA observed the facility to be clean, in good repair and to have sufficient furniture in common areas, both interior and exterior. LPA observed sufficient lighting throughout the facility, and had wall lights for night time from residents rooms to the central bathrooms. LPA viewed a locked outside gate, but lock was removed and will remain unlocked unless Licensee requests and exemption and fire clearance. LPA viewed a pool and spa in back yard with iron fence surrounding area. Fence locked at gate with pad lock. LPA viewed the thermometer for the running water at 118 degrees, and the refrigerator reading 40 degrees and the freezer reading 0 degrees. Facility had a 7+ day supply of non-perishables and an alarm sounding for when exterior doors are opened and closed. When viewing facilities fire extinguisher, LPA noticed no tag on one, and an expired tag on the other. Facility did not have a approved fire extinguisher at that time, but admin purchased extinguisher from COSTCO and emailed proof of purchase prior to report being completed. When viewing the living room, many activities were available. LPA saw the fire alarms and Co2 detectors were in working condition by the administrator testing them. When touring the kitchen, administrator showed LPA the locked cabinets for the sharps, no toxins are kept in the kitchen. LPA checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. LPA viewed a complete first aid kit. LPA viewed medication cabinet in the dining area, locked with a magnetic lock. LPA told admin and licensee that if medications need to be refrigerated, a separate fridge with a lock would be needed, or a lock box to be placed in a fridge that is used already.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SPLENDOR OAKS SENIOR LIVING #4	FACILITY NUMBER: 312700882
	VISIT DATE: 11/10/2020

NARRATIVE

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LPA observed the following posted at the facility: Resident Personal Rights, Rights of Resident/Family Councils, See Something Say Something, the Facility Sketch with evacuation routes, Ombudsman poster and the non-discrimination clause.

LPA reviewed the one (1) out of the four (4) resident files to ensure all appropriate documents were present. All appropriate documents were seen in file at this time.

Comp III was conducted during today's inspection.

Pre-Licensing is complete. There are no deficiencies cited at this time.

LPA Leitzell is to notify the analyst in the application unit of inspection being completed and follow-up documentation needed.

An exit interview was conducted with Kevin Lee, Licensee during today's tele-visit, and a copy of this report will be provided to the facility via email (sent 11/10/2020 at approximately 2:00p.m.) Two copies will be sent to the facility, 1 is to be signed and returned same day to CCL, and the other copy is to remain at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

LIC809 (FAS) - (06/04)

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