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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:18:29 PM


Document Has Been Signed on 05/11/2022 03:18 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:
05/11/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Dorcia Henry, caregiver TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to ensure facility is in compliance with Health and Safety Code ยง1569.38 Posting of licensing reports; disclosure to new residents following the department serving an Accusation on 4/27/2022. LPA met with Dorcia Henry, Calvin Copeland and David Dacosta, caregivers, who contacted Administrator, Bruce Foggy, by phone and explained purpose of inspection.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA confirmed there are no positive cases or staff/residents with symptoms, upon entering the community.

Administrator discussed with LPA the posted notice, dated 4/29/2022, displayed near the kitchen. LPA observed the notice to contain the required elements. Administrator indicated the Ombudsman was notified as well as all residents and their representatives.

LPA spoke with (2) residents regarding the receipt of a letter from the facility regarding a pending legal matter. Resident (R1) stated he was not advised but his children would have been. Resident (R2) stated she thinks she was advised and talked with LPA about wanting to use her walker to try and walk. LPA stated she would discuss with Administrator.

There are no deficiencies being cited today. Exit interview with Calvin. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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