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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:53:48 PM


Document Has Been Signed on 07/24/2024 03:53 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 PALM, THEFACILITY NUMBER:
342700535
ADMINISTRATOR:WILLIAMS, MARIAFACILITY TYPE:
740
ADDRESS:2839 CALIFORNIA AVETELEPHONE:
(916) 514-9421
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Williams, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Maria Williams, to conduct an inspection of the care home.

During visit, LPA observed resident (R1's) Physician's Report LIC 602A and observed that R1 was listed as "Bedridden." LPA observed that license for care home is not approved to accept and retain residents who are classified as bedridden per fire inspection. Facility is in the process of obtaining a fire clearance to accept and retain residents who are classified as bedridden. LPA also observed that R1 did not have a pre-placement appraisal completed prior to admittance to the care home.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on attached 809-D.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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Document Has Been Signed on 07/24/2024 03:53 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 PALM, THE
FACILITY NUMBER: 342700535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons. This requirement is not met as evidenced by:
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Facility is in the process of obtaining a fire clearance to accept and retain one (1) bedridden resident. LPA will follow up with facility regarding status of fire clearance.
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Based on records reviewed, facility did not ensure that they had a fire clearance for bedridden persons before accepting and retaining a resident who was considered bedridden according to their LIC 602A, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type B
07/30/2024
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
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Facility will complete an appraisal (LIC 603A) for resident R1 and submit document to LPA by POC due date of 7/30/2024.
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Based on records reviewed, facility did not ensure to conduct an appraisal for R1 prior to their admission to the facility, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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