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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:26:49 PM


Document Has Been Signed on 10/25/2023 12:26 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:
10/25/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maria Williams, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 10/25/2023 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 8/10/2022-8/10/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Maria Williams.

During today's visit, LPA reviewed the following stipulations of the order:

1. Staff shall be sufficient in number
-During inspection, LPA observed LIC 500s and staff schedule and found staff to be sufficient in number

2. Staff shall have CPR and First Aid
-LPA observed active CPR and First Aid cards for staff on site

3. Facility shall report unusual incidents
- LPA observed completed unusual incident reports sent to the Department

4. Facility shall allow visitation
-LPA observed visitor log on site

5. Staff shall have criminal background clearance
- LPA checked criminal background clearance for all staff

LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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