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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:36:42 AM


Document Has Been Signed on 05/16/2023 11:36 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 6DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Bruce FoggyTIME COMPLETED:
11:40 AM
NARRATIVE
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On 5/16/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit for a recently reported incident and met with Licensee/ Administrator .

On 5/9/23 The department received and incident report regarding on 5/9/23 on the overnight, R1 was able to leave the facility unattended. The facility has a door alarm system that the overnight staff did not hear the alarm sounded when R1 exited. R1 was found on an adjacent street and returned to the facility.
Staff reported that R1 was observed to be in bed at approximately 2:30 AM on 5/9/23. R1 was returned to the facility by police at approximately 4:25 AM on 5/9/23. R1 was assessed and was unharmed during the absence.

Licensee has upgraded the alarm to R1's room to bee more clearly heard. There have been no further incidents. R1 was reported to not have had prior exit seeking behavior.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. 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: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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 05/16/2023 11:36 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
CCR
87705(b)(2)

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Care of Persons with Dementia. (b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
This requirement was not met based on observations and interviews finding the alarm system was insufficient to
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Licensee has upgraded the door alarm for R1's room to be audible throughout the home. R1 now has increased monitoring.

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alert staff to a resident leaving. This posed an immediate risk to R1.
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Licensee will submit a plan for a new LIC 602 and care plan for R1 as well as the planned upgrade of alarms sytem in the home for all resident, by the POC date of 5/23/23.

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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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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