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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:23:00 PM


Document Has Been Signed on 05/11/2022 04:23 PM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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:
05/11/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Mario Forsythe and Leonie Broadbelt, caregivers TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to ensure facility is in compliance with Health and Safety Code §1569.38 Posting of licensing reports; disclosure to new residents following the department serving an Accusation on 4/27/2022. LPA met with Mario Forsythe and Leonie Broadbelt, caregivers, who contacted Administrator, Bruce Foggy, by phone and explained purpose of inspection. Administrator arrived at facility at approximately 3:55 pm.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA confirmed there are no positive cases or staff/residents with symptoms, upon entering the community.

Administrator and LPA discussed the posted notice, dated 4/29/2022, displayed in the corner of the wall in the front room near other CCLD documents. LPA suggested that the notice be placed in a more conspicuous location, in the kitchen, next to other postings. Caregiver reposted the notice during today's inspection.

LPA observed the notice to contain the required elements. Administrator indicated the Ombudsman was notified as well as all residents and their representatives. LPA spoke with (1) resident regarding the receipt of a letter from the facility regarding a pending legal matter. Resident (R1) stated she was not advised but her children would have been. LPA spoke to resident (R2's) partner, who stated resident recently moved in and was not informed. by Administrator. Administrator stated resident should have been notified during admission process. Administrator agrees to follow up by email with all residents/representatives. Discussed §1569.38.

There are no deficiencies being cited today. Exit interview with Administrator. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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