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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700871
Report Date: 01/22/2021
Date Signed: 01/22/2021 04:46:07 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:
01/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ben Massioui, LicenseeTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Sabrina Calzada and Pheej Cheng arrived unannounced to conduct a health and safety check. LPA's were cleared to conduct field visits prior to visit. LPA's wore N95 masks upon entering the facility. LPA's met with Ben Massioui, Licensee, and explained purpose of inspection. LPA's observed (4) residents and (1) caregiver present.

During today's inspection, LPA's toured the interior and exterior of the facility and found the facility to be clean and in good repair. LPA's observed and spoke to each resident who appeared to be clean and wearing clean clothes. LPA's observed 2+day perishable and 7+day non-perishable food supplies on hand. LPA's observed locked medications being stored in the kitchen and sharps and toxins to be locked in the kitchen. LPA's observed PPE supplies and paper products. LPA's observed (2) unlocked gates outside and did not observe any fountains or other bodies of water. LPA's reviewed resident records.

The following deficiencies were observed during today's inspection and cited on the 809D attached:

LPA's were not screened per required Covid-19 precautionary measures prior to entering facility and observed there are no signs posted regarding visitor. Facility was not able to visitor temperature log and symptoms screening questions. LPA's observed Licensee to initially answer the front door not wearing a protective face covering.

Licensee failed to notify the department of new residents within (5) business days of 12/10/2020 when residents moved in.


cont on 809C.....
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 342700871
VISIT DATE: 01/22/2021
NARRATIVE
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LPA's observed all resident files to have a missing or outdated care plan and/or physician report.

LPA's observed that exit doors do not have an auditory device to alert staff, as required for care of residents with a diagnosis of dementia.

Per California Code of Regulations Title 22, Division 6, Chapter 8, the following (4) deficiencies are cited. Failure to correct by the noted due date may result in a penalty being assessed.

Exit interview conducted with staff Marie Walker. Licensee was not present at facility when LPA's returned to deliver report. Staff Marie contacted licensee and LPA's confirmed by phone with Licensee that Marie is authorized to sign today's report. Copy of report and appeal rights left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 342700871
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/23/2021
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
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Based on observation, the Licensee did not ensure that LPA's were screened per Covid-19 precautionary measures upon entering the facility, was not initially wearing a mask upon answering the door, and did not have the Covid visitation policy posted on the front door, on 1/22/2021,
which posed an immediate health and safety risk to residents in care.
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Type B
02/05/2021
Section Cited

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87755 Inspection Authority of the Licensing Agency (d) The licensing agency shall have the inspection authority as specified in Health and Safety Code Sections 1569.24...Within 90 days after a facility accepts its first resident for placement following its initial licensure, the department shall inspect the facility to evaluate compliance with rules and regulations and to assess the facility's continuing ability to meet regulatory requirements. The licensee shall notify the department, within five business days after accepting its first resident for placement, that the facility has commenced operating. This requirement is not met as evidenced by:
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Based on regional office records, the Licensee did not ensure that the department was notified within 5 days of 12/10/2020 when the first resident moved in, which posed a potential health and safety risk to residents.
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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: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 342700871
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2021
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Based on record review, the Licensee did not ensure that residents in care have a current care plan and/or physician's report on record, which poses a potential health and safety risk to residents in care. Review of records indicated that 4 of 4 residents had an expired care plan or physician's report that was not updated within the last 12 months.
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Type B
02/05/2021
Section Cited

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
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Based on observation, the Licensee did not ensure that all exit doors have an auditory device or other staff-alert feature to monitor exits, which poses a potential health and safety risk to residents in care.
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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: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4