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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:00:51 PM


Document Has Been Signed on 07/13/2023 02:00 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/13/23 to conduct a Required-1 Year Inspection utilizing the CARE inspection tool. LPA met with Caregiver and explained the purpose of the visit . Administrator arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed 5 resident files and 4 staff files. LPA found residents to be complete
LPA and Admin discussed the following topics: correct LIC 602 errors, staff training documented as outlined in reference material provided, CCLD's medication guide for information and best practices, all medication orders are signed, staff that are associated but not recorded in Guardian, Fire drills are documented and the fire door release was found to malfunction and will be repaired.
Infection control plan is on file.

Licensee requested a copy of liability insurance.

As a result of this inspection, no deficiencies were found.

Report reviewed with licensee . Copy of this report.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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