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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 02/07/2023
Date Signed: 02/07/2023 06:38:51 PM


Document Has Been Signed on 02/07/2023 06:38 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
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: 5DATE:
02/07/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Bruce FoggyTIME COMPLETED:
04:30 PM
NARRATIVE
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On 2/7/23, Licensing Program Analyst (LPA) Kevin arrived at the facility to conduct a quarterly case management visit regarding the facility's probation status. LPA met with Administrator, Maria Williams and Bruce Foggy, and explained the purpose of the visit. At entrance, LPA observed two (1) staff not wearing a face covering/mask. LPA informed Administrator mask is still mandated by the Department. No screening was done

LPA observed six (5) residents present at the facility. Facility was able to show LPA a copy of the LIC 500 during the visit. LPA reviewed personnel files- 1st aid/ CPR. LPA confirmed on Guardian website, S1 is not associated with the facility. Proof of transfer request to all licensee's facilities was present. Licensee will forward the email of request.

LPA observed the stipulation waiver and order to be posted in the facility. LPA and Administrator confirmed the facility to have a file obtaining all the documents required for review during probation period.

The home is clean and in good repair. There was sufficient staffing for resident needs

LPA requested the quarterly staff schedule to be emailed to LPA by Friday February 10,2023 .
During today's visit, deficiencies were observed. Please see attached LIC 809-D. Facility smoke detector system was not operating properly with alarms chirping and one wired detector had been removed for an unknown time.

Exit interview conducted, and a copy of the report and appeal rights was emailed to Administrator, Bruce Foggy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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Document Has Been Signed on 02/07/2023 06:38 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: SPLENDOR OF CARMICHAEL AT PALM, THE
FACILITY NUMBER: 342700535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by observation and interview
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Licensee will contct Cal fire to report the incident and submit the corrective action to CCL by the POC date of 2/8/23
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that at least 2 smoke detectors are not operating properly. This posed an immediate risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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