<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700871
Report Date: 11/25/2020
Date Signed: 11/25/2020 04:16:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BM MEMORY CARE AND ASSISTED LIVINGFACILITY NUMBER:
342700871
ADMINISTRATOR:MASSIOUI, BENFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(916) 883-8400
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
11/25/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Ben MassiouiTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melana Llopis conducted a prelicening inspection via tele-visit on 11/25/2020 at 12:00PM due to Cvodi-19 and precautionary measures. LPA met with Administrator, Ben Massioui. The facility has a fire clearance for six (6) non-ambulatory residents. No residents were present during time of visit.

Administrator and LPA toured the facility via video conferencing and observed the following areas: four (4) resident bedrooms, two (2) resident bathrooms, kitchen, living room, laundry area, and outdoor area. The facility appeared to be in good repair at time of inspection and equipped with smoke detectors throughout the home, carbon monoxide detector is also present. Facility has sufficient cleaning supplies and a locked cabinet for medications, knives were observed to be inaccessible. Resident bathrooms had required grab bars and non-skid mats. LPA and administrator discussed what food supply would look like when facility is in operation and licensee understands a 2-day perishable and 7-day non-perishable needs to be on hand at all times.

Facility staff file was found to be current and complete.
Required signs were observed throughout the facility.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.
Component III was completed.
LPA will contact the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

Exit interview conducted and copy of report was emailed to licensee, signed copy to be returned to Community Care Licensing, a signed copy should be retained for facility records.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1