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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:30:45 AM


Document Has Been Signed on 05/16/2024 11:30 AM - 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:WILLIAMS, MARIAFACILITY TYPE:
740
ADDRESS:4921 KEANE DRIVETELEPHONE:
(916) 514-9173
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Waria WilliamsTIME COMPLETED:
11:30 AM
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On 5/16/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator, Maria Williams.

LPA was following up to see if the licesnee has any medical records for R1's hospitalization and rehab following R1's 3/20/24 fall. LPA informed R1's Responsible party (Rp) has records if available. LPA received confirmation of the Rp's contacts.

R1 is returned to the facility and was observed in the community.

As a result of today’s inspection, no deficiencies were noted.


Report reviewed. Copy of report and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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