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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700821
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:16:12 PM


Document Has Been Signed on 05/17/2023 05:16 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keith HamricTIME COMPLETED:
05:30 PM
NARRATIVE
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On 5/17/2023 at 1:30 PM, Licensing Program Analyst (LPA) Cassie Yang and Associate Governmental Program Analyst (AGPA) Matt Sparling arrived unannounced at the facility to conduct a Required-1 year inspection. LPA and AGPA met with caregiver, Stephanie Martinson, who contacted Licensee/Administrator, Keith Hamric, who arrived to the facility at approximately 2:05 PM. LPA and AGPA explained the purpose of the visit. LPA and AGPA wore the following Personal Protective Equipment; surgical mask.

Facility is licensed for capacity of six (6) with hospice waiver of 4. Facility's census is six (6) with two (2) on hospice services. LPA will provided Licensee an updated license.

During today's visit, LPA and AGPA toured the interior of the facility with Licensee. In areas toured included but not limited to: common areas, resident bedrooms, bathroom, kitchen, garage and laundry/medication room. At 2:15 PM, LPA, AGPA and Licensee entered the locked garage and found cleaning solutions on the floor. Additionally at 2:25 PM, LPA observed the fire extinguisher to be last serviced 9/9/2021. LPA was informed it may have been a mistake as the extinguisher has been serviced recently.

LPA and AGPA conducted a personnel and resident file review and deficiencies were observed. Please see attached LIC 809-D.

LPA, AGPA and Licensee was unable to complete the CARE tool during today's inspection, annual continuation is to follow.

Exit interview conducted and a copy of the report and appeal rights was provided to Licensee.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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 05/17/2023 05:16 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: BLUEBERRY HILL SENIOR LIVING, INC.
FACILITY NUMBER: 342700821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)
87411 Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review conducted, the licensee did not comply with the section cited above as 1 out of 5 staff did not have a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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S1 is not allowed to work at the facility until clearance is obtained.
Licensee is to review and submit a statement of compliance to CCR 87411 to CCLD by close of business day 5/18/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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