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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 11/06/2020
Date Signed: 11/16/2020 09:24:42 AM

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 OF CARMICHAEL AT KEANE, THEFACILITY NUMBER:
342700534
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:4921 KEANE DRIVETELEPHONE:
(916) 514-9173
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
11/06/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bruce FoggyTIME COMPLETED:
10:30 AM
NARRATIVE
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On 11/6/20, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Bruce Foggy, Administrator of facility The Splendor of Carmichael at Keane – 342700534 at approximately 10 AM. LPA was unable to meet at the facility due to current circumstances.

The purpose of this visit was to follow up on deficiencies found during the course of investigating complaint number 27-AS-20200518150520.

Statements, records and photograph found that medication for R1 was included in discharge medication supplies for R4 in June 2020 . Upon admission to R4‘s new home, the error was discovered and the medication was destroyed by a hospice nurse.

Statements found that during the course of this investigation that R1 and R3 had diseased and facility failed to report the death as required.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk to clients/residents in care.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Administrator, Bruce Foggy to sign. Administrator to send a signed copy back to CCL.
(add if substantiated) Additionally, LPA sent a copy of the appeal rights.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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 OF CARMICHAEL AT KEANE, THE
FACILITY NUMBER: 342700534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2020
Section Cited

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Incidental Medical and Dental Care(i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other
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adult who is not a resident. This requirement was not met based on statements, records and photo. This posed a potential risk to the resident.
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Type B
11/13/2020
Section Cited

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Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...(A) Death of any resident ...
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This requirement was not met based on statements and records. This posed a potential risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2020
LIC809 (FAS) - (06/04)
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