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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700871
Report Date: 01/24/2021
Date Signed: 01/24/2021 12:44:37 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:WHEELER, SHANTEFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(916) 333-4459
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6; 6CENSUS: 4DATE:
01/24/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Ben Massioui, Acting AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA's) Sabrina Calzada and Pheej Cheng arrived unannounced to conduct a follow up health and safety check. LPA's wore N95 masks and were cleared to go in the field prior to the visit. LPA's were greeted by Ben Massioui, Acting Administrator, and explained purpose of inspection. LPA's observed "No Visitor" policy posted outside front entrance. LPA's observed Acting Administrator and (2) staff present- all were wearing masks during the inspection.

LPA's observed (2) residents to be awake and (2) residents to be asleep upon arrival. LPA's spoke to (2) residents and no concerns were noted. Breakfast was served earlier today- (1) resident confirmed she ate breakfast and (1) resident stated he slept in. LPA's observed staff to be wearing masks and resident who was walking around to also be wearing a mask.

LPA's reviewed the report issued last Friday, 1/22/21 and addressed any concerns Acting Administrator had. LPA's confirmed appeal rights and printed another copy of second page as it had not fully printed previously. LPA's reiterated the Plan of Corrections.

LPA's observed staff member to be preparing lunch during today's inspection.

There are no deficiencies being cited during today's inspection.

Exit interview. Copy of report provided to Acting Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2021
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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