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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 05/14/2021
Date Signed: 05/14/2021 11:12:43 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 PALM, THEFACILITY NUMBER:
342700535
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:2839 CALIFORNIA AVETELEPHONE:
(916) 514-9421
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 2DATE:
05/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Bruce FoggyTIME COMPLETED:
11:15 AM
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On 5/14/2021 at 10:55 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted Administrator, Bruce Foggy, 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. LPA observed staff listed on the LIC 500 present at the facility working.

No deficiencies cited.

An exit interview was conducted with Administrator, Bruce Foggy, 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (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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