342700534-5-14-2021-25-AS-SKEG-C2ZN98-20210514101531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700534
Report Date: 05/14/2021
Date Signed: 05/14/2021 10:15:53 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, THE		FACILITY NUMBER:	342700534
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	4921 KEANE DRIVE		TELEPHONE:	(916) 514-9173
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 3	DATE:	05/14/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Williams		TIME COMPLETED:	10:00 AM

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On 5/14/2021 at 9 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted Administrator, Maria Williams, to conduct an unannounced Case Management Tele-visit. LPA explained the purpose of the telephone call.

An office visit was conducted which outlines the expectations of the facility. Administrator agrees to send Community Care Licensing (CCL) weekly schedule updates to ensure CCL have the most current staffing schedule.

LPA was granted entry into the facility via Facetime. LPA toured the interior of the facility with Administrator to ensure there are no health and safety concerns.

LPA reviewed current LIC 500 provided by the facility on 4/30/2021. The LIC 500

LPA requested for updated care plans for all residents in care.

No deficiencies cited.

An exit interview was conducted with Administrator, Maria Williams, and a copy of this report will be provided to the facility via email. This report is to be signed and returned to LPA via email.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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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