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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700878
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:38:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING #3FACILITY NUMBER:
342700878
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVETELEPHONE:
(916) 241-9603
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:12CENSUS: 9DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Rowan (Ann) Williams, lead caregiverTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Rowan "Ann" Williams, , lead caregiver, who contacted Maria Cucicea, House Manager/Co-Administrator by phone. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility currently has (9) residents and (1) resident is on hospice. LPA observed (4) residents to be in the front room watching television and (5) residents to be in their room, sleeping, reading or with a physical therapist. The facility is licensed for (12) non-ambulatory residents and has a hospice waiver for (6) residents. Facility has live-in caregiver staff. LPA confirmed there are (3) caregivers scheduled for all day shifts and (1) awake staff during the nights. LPA observed (3) caregivers presednt and lead careagiver- all caregivers were wearing a mask.

LPA and caregiver, Ann, toured the interior of the facility. LPA observed it to be clean, in good repair and to be odor free. LPA observed various Covid posters throughout the facility. Rooms toured include (10) private bedrooms, (1) shared resident bedroom, (3) bathrooms, kitchen, laundry, and common areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and lead caregiver completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 75 F. Fire extinguishers last serviced 5/28/2021 and smoke/monoxide alarms are in working order, LPA observed sufficient 2+day perishable and 7+day non-perishable food and PPE supply. LPA observed paper towels, soap and sanitizer in the bathrooms. LPA recommended to post 12 -step hand-washing posters by each sink. Sharps, toxins and medications are secured appropriately. Vaccination status of residents and staff and PIN 21-40 issued 8/27/2021 regarding visitation protocols was discussed. . All staff are cleared and requested to be associated to the facility. Administrator Iana Voitehovschi #6056473740- exp 7/12/2022- posted during inspection since Kevin Lee's renewal is pending.
cont on 809C..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SPLENDOR OAKS SENIOR LIVING #3
FACILITY NUMBER: 342700878
VISIT DATE: 11/22/2021
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LPA observed required postings including LTCO, See Something Say Something and Resident Rights, LIC308's (for multiple staff), Non-Discrimination notice and menu.

LPA requested an updated copy of LIC500 and current liability insurance to be emailed/faxed to the Department by 11/30/2021.

There were no deficiencies observed during today's inspection. Exit interview with lead caregiver, per House Manager.

Copy of report to be e-mailed to Administrator following inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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