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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700534
Report Date: 11/06/2020
Date Signed: 11/06/2020 10:46:10 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2020 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20200518150520
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bruce FoggyTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Residents' personal rights were violated.
INVESTIGATION FINDINGS:
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On (date), 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.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.
A document submitted, on 5/28/20, showed that a notification of work to be completed was created by the Administrator on 4/22/20. However, copies of email communications find the Administrator acknowledging the error in the notice not having been delivered to resident responsible parties. Residents and responsible parties were not all informed of work to be done prior to disruptions to room access and services in the home.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20200518150520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/06/2020
NARRATIVE
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87468.1(a)(8) Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services… This requirement was not met based on statements which found three of five residents at the time flooring work was done were not notified prior to work being initiated. This posed a potential risk to residents’ personal rights.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-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, or personal rights violation, 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.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200518150520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services… This requirement was
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Licensee will submit a statement of understanding of this requirement to CCL by the POC date of 11/13/20.
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 not met based on statements which found three of five residents at the time flooring work was done were not notified prior to work being initiated. This posed a potential risk to residents’ personal rights.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2020 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20200518150520

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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bruce FoggyTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Unsafe environment
INVESTIGATION FINDINGS:
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On (date), 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.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
US for unsafe environment- Facility clearly did not appropriately do daily Covid screening for Juan (and his co-workers). But this was recommendations and not in statute. In April- May the guidelines for mask use were unclear for general movements within the house by staff, visitors, contractors. Facility procedures insured that the workers were clearly separated from residents by physical barriers and space.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200518150520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/06/2020
NARRATIVE
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As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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.

Exit interview with administrator.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5