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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700882
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:10:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING #4FACILITY NUMBER:
312700882
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:6905 POCA MONTOYA DRTELEPHONE:
(412) 608-2690
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maureen HydeTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10//2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff, Maureen Hyde, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to contact administrator, Maria Cucicea, to notify administrator of LPA's presence at the facility to conduct an annual inspection. Staff notified administrator via telephone. Administrator stated she is unable to meet LPA at the facility and gave permission for staff to sign report.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, administrator, and staff completed the infection control domain via telephone and facility was found to be in substantial compliance at this time.

LPA requested for Administrator to submit documents to Community Care Licensing by 10/20/2021.
  • Administrator Certificate
  • Designation of Administrative Responsibility LIC 308
  • Liability Insurance
  • Control of Property- Grant Deed or Rental Agreement

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted with staff and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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