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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700821
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:13:13 PM


Document Has Been Signed on 05/22/2024 03:13 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: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: 5DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dana Ford and Keith HarmicTIME COMPLETED:
04:10 PM
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On 5/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPA met with Caregiver who then contacted Administrator who then arrived to the facility shortly.

LPA observed the presence of five residents in care, two residents were in their private rooms and three residents in the common area, watching television.

During today's inspection, LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents room, bathroom, garage, kitchen, and the common areas. LPA observed the sharps to be locked and secured in the kitchen. LPA observed the facility to have 2+ days of perishables and 7+ days of nonperishable foods. LPA observed facility to have ample supply of linens for residents in care. LPA observed facility to be clean, sanitary and in good repair.

LPA and Administrator discussed the definition of non-ambulatory as Title 22 defines non-ambulatory as a "persons who are unable, or likely to be unable, to respond physically or mentally to an oral instruction relating to fire danger". LPA discussed with Administrator that Bedroom 1 may be non-ambulatory if a direct exit door is installed.

File review conducted five residents and four personnel files. LPA completed the care tool and found facility to be in compliance to California Code of Regulations, Title 22.

No deficiencies cited.

Exit interview and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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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