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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700878
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:42:59 PM

Document Has Been Signed on 12/10/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING #3FACILITY NUMBER:
342700878
ADMINISTRATOR/
DIRECTOR:		LEE, KEVINFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVETELEPHONE:
(916) 241-9603
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 12CENSUS: 10DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Audre SmithTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived unannounced to conduct an annual inspection. LPAs met with Administrator Audre Smith during today's inspection.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are nine (9) bedrooms and five (5) bathrooms for resident use. LPAs observed rooms 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 115.1 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPAs checked medication storage and found medications to be locked away and inaccessible to the residents. LPAs reviewed ten (10) resident files, four (4) staff files and two (2) resident medications. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy.

As a result of this visit, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. The deficiency is listed on 809-D pages. Appeal rights given.

Exit interview was conducted with Administrator. A copy of this report.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 03:42 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 12/10/2024 at 03:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SPLENDOR OAKS SENIOR LIVING #3
FACILITY NUMBER: 342700878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations and records reviewed, the licensee did not ensure that newly hired staff completed intial training within the first four weeks of employment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Facility will ensure staff are receiving intial training per Health and Safety Code within the first four weeks of employment. Facility will complete a statement of understanding and submit statement to LPA by POC due date.

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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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