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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:23:46 PM


Document Has Been Signed on 12/12/2022 03:23 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
CHICO - RESIDENTIAL, 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:
12/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Williams and Bruce FoggyTIME COMPLETED:
02:15 PM
NARRATIVE
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On 12/12/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a quarterly case management visit regarding the facility's probation status. LPA met with Administrator, Maria Williams and Bruce Foggy, and explained the purpose of the visit. At entrance, LPA observed two (2) staff not wearing a face covering/mask. LPA informed Administrator mask is still mandated by the Department.

LPA observed six (6) residents present at the facility. Facility was not able to provide LPA a copy of the LIC 500 during the visit. LPA reviewed only two (2) out of eight personnel files, S1 and S2, to be present at the facility. LPA confirmed on Guardian website, S1 and S2 are not associated with the facility. LPA informed Administrators that all staff needs to have a personnel file at each facility and to be associated with the facility.

LPA printed and provided a copy of probational license to Administrator during today's visit. LPA did not observed the stipulation waiver and order to be posted in the facility. LPA informed Administrator based on the signed document by Administrator and Licensee, signed on July 25, 2022 effective August 10, 2022, facility agreed to the terms and condition of posting the document in a conspicuous space. LPA and Administrator discussed the facility to have a file obtaining all the documents required for review during probation period. LPA and Administrator further discussed facility needs to submit LIC 9182, a copy driver's license and LIC 508 to CCLD for clearance transfer.

LPA requested the quarterly staff schedule to be emailed to LPA by Friday December 23, 2022.
During today's visit, deficiencies were observed. Please see attached LIC 9102's, LIC 809-D and LIC 421BG.

Exit interview conducted, and a copy of the report and appeal rights was emailed to Administrator, Bruce Foggy.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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Document Has Been Signed on 12/12/2022 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: SPLENDOR OF CARMICHAEL AT KEANE, THE
FACILITY NUMBER: 342700534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
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Licensee and LPA will associate S1 and S2 immediately.
Licensee is to associated staff at the facility prior to staff working at the facility.
Licensee will submit a statement of complaince to CCLD via email by 12/13/2022.
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Based on observation and interview, Licensee did not ensure S1 and S2 were associated with the facility prior to employment as S1 has been employed at the facility since August 2022 and S2 has been employed since September 2022, which posed an immediate health and safety risk for residents in care.
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Type B
12/23/2022
Section Cited

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87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by:
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Licensee is to submit statement of compliance of the regulation, along with a plan of how facility will have records available for review to CCLD via email by 12/23/2022.
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Based on observation and interview, Licensee did not ensure personnel records were available for Licensing to review as LPA observed the facility to only have 2 out of 8 caregivers file available, which posed an potential health and safety risk for 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2