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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 04/22/2021
Date Signed: 04/27/2021 10:44:32 AM

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:
04/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria Williams, Lead staff/Co-AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility on 4/22/2021 @11:00 am to conduct a health and safety check. LPA was wearing an N95 mask and was cleared per department protocol prior to going in the field. LPA remained outside during the inspection and spoke to Maria Williams, Lead Staff/Co-Administrator, at the front door. LPA identified herself and explained the purpose of today's inspection. Maria confirmed there are currently (5) residents living at the facility.

LPA interviewed Maria who indicated that she and the Administrator are the only (2) staff currently working at the facility. Maria confirmed that the owner/Administrator was currently at another related facility with another staff.

LPA requested an LIC500 or staffing schedule. Maria stated she would follow up and inform the Administrator that CCLD made an inspection. LPA received a completed LIC500 from the Administrator, Bruce, on 4/25/2021.

There are no deficiencies being cited today.

Due to technological issues during the inspection, an exit interview was conducted with Administrator, Bruce Foggy, on 4/27/2021@10:30 am by phone. A copy of this report will be emailed to Administrator to sign and return a copy following today's call.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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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