342700534-4-3-2024-59-AS-KMKY-D3YV6N-20240403160948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:09:56 PM

Document Has Been Signed on 04/03/2024 04:09 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, THE		FACILITY NUMBER:	342700534
ADMINISTRATOR: ADMINISTRATOR/ DIRECTOR:	WILLIAMS, MARIA		FACILITY TYPE:	740
ADDRESS:	4921 KEANE DRIVE		TELEPHONE:	(916) 514-9173
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/03/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN: TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Maria Williams		TIME COMPLETED: TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/3/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator. On 3/20/24, the Department received an incident report, completed by Alex Tellez, that stated, “ On Wed. March 20 at ~~6:48 AM~~ around 7 AM, (S1), employee called Martha to notify her that (R1) had a fall…” The report further stated that, ” proper protocol was taken by assessing the client (R1), calling 911…” The department received a staff statement there was a tall, male person brought in for overnight coverage and that person found R1 on the floor and bleeding. That male person assisted S1 in getting R1 back to bed. S1 stated that they were alerted, by this other person who was introduced as Danzel, to R1 having had a fall at approximately 6:30 AM on 3/20/24. S1 stated that “Danzel” began work on the evening of 3/19/24. Others interviewed witnessed that a person matching Danzel's description was present at the home. S1 stated that they did in fact call to Martha Tufo regarding the incident and that Martha requested S1 not call 911 until Martha could arrive to assess R1. Martha told LPA that Martha directed S1 to call 911 while Martha was on the way to the home.

Maribeth Senty	TELEPHONE: (916) 263-4813
Kevin Mknelly	TELEPHONE: (209) 814-1925
	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 342700534
	VISIT DATE: 04/03/2024

NARRATIVE

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Family of R1 stated that R1 sustained a broken hip that required surgery.

LPA received a statement from a witness who saw “Danzel” present at the facility on the morning of 3/20/24.
LPA asked Martha Tufo and Alex Tellez if there was another person present the night of 3/19/24-3/20/24. Neither acknowledged that another person was present.

LPA requested access to the facility’s video recording and was told that they no longer have access to it.

The incident which failed to identify the time of R1’s fall, that the 911 protocol was followed and failure to identify the person present identified as Danzel, constitute false statements.

In addition to Danzel being present at the facility, Martha Tufo also has not been finger-print cleared or transferred to work at the facility. This constitutes a violation of criminal record clearance requirements.

No personnel records were available when requested for Danzell.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed, report copy and appeal rights provided

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/03/2024 04:09 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SPLENDOR OF CARMICHAEL AT KEANE, THE	FACILITY NUMBER: 342700534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/04/2024 Section Cited CCR 87207	1 2 3 4 5 6 7	False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met based on witness statements.	1 2 3 4 5 6 7	Licnesee will submit a statement with plan to review training with all staff for the expectation of providing truthful statements to the department .
Request Denied Type A 04/18/2024 Section Cited CCR 87355(b)(1)	1 2 3 4 5 6 7	Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department	1 2 3 4 5 6 7	Current employees were found to be cleared and associated. Licensee or designee will provide proof of training and establishing an account with Guardian in order to manage and monitor employee clearances by the POC date of
	8 9 10 11 12 13 14	This requirement was not met based on statements and records that found a staff on 3/20/24 and a member of the licensee LLC were not cleared and associated to the home. This posed a risk to residents.	8 9 10 11 12 13 14	4/18/24.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Maribeth Senty	TELEPHONE: (916) 263-4813
Kevin Mknelly	TELEPHONE: (209) 814-1925
	DATE: 04/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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