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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700878
Report Date: 12/02/2020
Date Signed: 12/02/2020 03:54:27 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:SPLENDOR OAKS SENIOR LIVING #3FACILITY NUMBER:
342700878
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVETELEPHONE:
(412) 608-2690
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:12CENSUS: 7DATE:
12/02/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Administrator, Kevin LeeTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Angela Hood contacted the Administrator, Kevin Lee, via telephone to conduct a virtual pre-licensing inspection of the facility. The visit was conducted via telephone due to COVID-19 and precautionary measures. Applicant holds current administrator certificate #6053688740 exp. 9/24/21. There are currently 7 residents residing in the care home.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are seven bedrooms and three bathrooms for resident use. LPA observed bedrooms 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 110 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents.

LPA observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. Smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA reviewed one resident file and one staff file.

Pre-licensing passed and Component III has already been completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of this report shall be submitted to CCLD. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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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