342700821-3-13-2025-59-AS-CMIN-DEQPNC-20250313112742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700821
Report Date: 03/13/2025
Date Signed: 03/13/2025 11:27:48 AM

Document Has Been Signed on 03/13/2025 11:27 AM - 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/ DIRECTOR:	HAMRIC, KEITH		FACILITY TYPE:	740
ADDRESS:	3827 OLIVE LANE		TELEPHONE:	(916) 900-8399
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Keith Hamric, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Keith Hamric to conduct an annual inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) resident rooms and two (2) common area bathrooms. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 109.7 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files, three (3) staff files and resident medications.

Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.

Laura Munoz	TELEPHONE: (916) 709-6317
Cassandra Mikkelson	TELEPHONE: (916) 709-6830
	DATE: 03/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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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