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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 05/19/2021
Date Signed: 05/19/2021 01:06:13 PM

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:
05/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:31 AM
MET WITH:Maria Williams- Co Administrator TIME COMPLETED:
01:15 PM
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On 5/19/2021 at 12:10 AM, Licensing Program Analysts (LPAs) Sarena Keosavang and Jacob Williams arrived at the facility to conduct an Unannounced Case Management visit. LPAs met with Administrator, Maria Williams, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask and surgical mask.

LPA explained the purpose of the visit was to follow up on an incident that was reported to Community Care Licensing (CCL). Resident's (R1) Responsible Party (RP) contacted the Administrators, Bruce Foggy and Maria Williams, to request for R1's notes and records including prescription logs. RP had requested for R1's documents from Administrator three times and facility did not provide it.

LPA requested for Administrator to send copies of R1's requested documents to R1's RP before LPA leaves the facility.

No deficiencies cited.

An exit interview was conducted with Administrator, Bruce Foggy, and a copy of this report will be provided to the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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