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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700821
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:16:47 PM


Document Has Been Signed on 05/13/2022 12:16 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:BLUEBERRY HILL SENIOR LIVING, INC.FACILITY NUMBER:
342700821
ADMINISTRATOR:HAMRIC, KEITHFACILITY TYPE:
740
ADDRESS:3827 OLIVE LANETELEPHONE:
(916) 900-8399
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Christina Pena, caregiver TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Christina Pena, caregiver, who contacted Administrator by phone. LPA spoke to Administrator, Keith Hamric and Activities Director, Megan Hamric, who were not able to be at the facility right away. LPA explained that annual inspection today is focused on Covid-precautionary measures in place. Administrator authorized caregiver to provide information, as needed, to LPA and sign today's report.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask.

LPA observed (4) residents in the common area watching television, and (2) residents to be resting in their rooms. There is currently (1) resident on hospice services.

LPA and caregiver toured the interior and exterior of the facility, including (4) private resident bedrooms, (1) shared resident bedroom, (2) bathrooms, kitchen, common areas, laundry/medication room, and garage/storage area. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 74* F. Fire extinguisher last serviced 9/10//2021. LPA observed locked toxins, medications and sharps and sufficient 2+day perishable/7+day non-perishable food. First aid kit on site.. Exit doors have alarms on them. LPA observed paper towels, soap, sanitizer, and hand-washing posters in the bathrooms. LPA observed sufficient PPE supply and incontinent products. There is (1) outside gate that is unlocked from the inside. LPA observed various Covid posters throughout as well as other required postings. LPA observed Provider Information Notices (PIN) issued by the Department and the Emergency Disaster Plan (LIC610E) to be available for staff review in the medication room. report continued on 809C...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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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: BLUEBERRY HILL SENIOR LIVING, INC.
FACILITY NUMBER: 342700821
VISIT DATE: 05/13/2022
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Discussed vaccination status of residents and staff with Administrator and observed facility to be maintaining records of visitor and staff vaccination status. Discussed scheduling a first or second booster shot with families of residents that have not received it yet.

LPA requested an updated copy of LIC308, LIC 500, current liability insurance and Administrator RCFE certificate be provided to the Department by 5/20/22.

There were no deficiencies observed during today's inspection.

Exit interview with caregiver. 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: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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