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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:16:34 PM


Document Has Been Signed on 08/22/2022 04:16 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: 6DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Bruce Foggy, Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Mario Forsythe and David Dacosta, caregivers, and explained purpose of inspection. Bruce Foggy, Administrator, arrived at the facility at approximately 1:45 pm when Maria Williams, Co-Administrator also arrived. LPA observed (3) residents in the common area watching television and (3) residents to be in their rooms at the start of the inspection. Currently, there are (2) residents on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3).

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (6), kitchen, staff room and laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters posted in shared bathroom/shower room. Administrator to ensure hand-washing posters are posted by each sink. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps in the kitchen. LPA observed toxins and medications to be secured in the laundry room and in a separate cabinet. LPA observed the fire door to be kept open by an approved fire device and the fire extinguisher to have been last serviced 9/1/2021-annual maintenance has been scheduled. LPA observed the inside temperature to be 76*F. LPA observed (2) unlocked outside gates from the inside and a pool that is gated with a combination padlock. There is seating with shade covering also. First kit kid on site and smoke/monoxide alarms are functioning properly.
cont on 809C..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 342700534
VISIT DATE: 08/22/2022
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809C...Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols. All staff are cleared/associated. Administrator certificate # 6003533740- exp 8/26/2023 for Maria A, Williams. Bruce Foggy, Administrator to post the current copy of Administrator certificate # 6046548740- exp 12/11/2022

Administrator, Maria, stated that all staff training is current.

LPA briefly discussed follow up to inspection on 5/11/22. Notice is still posted in common area of facility.

LPA provided some sanitizers and gloves from Regional Office supply during today's inspection.

LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance be provided to the CCLD by 8/31/22 and a copy of the Infection Control Plan if not already sent in.

There are no deficiencies issued during today's inspection.

Exit interview. Copy of report emailed to Administrator, Bruce following today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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