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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700878
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:50:22 PM


Document Has Been Signed on 12/19/2023 02:50 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:LEE, KEVINFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVETELEPHONE:
(916) 241-9603
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:12CENSUS: 10DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Ann Williams, Facility ManagerTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/19/23 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA 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. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 112.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home. LPA observed smoke detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87203 regarding obstruction of fire exits in bedroom 1 and side gate, and carbon monoxide detectors not being installed. Deficiency is listed on 809-D. An immediate civil penalty per Health and Safety Code ยง 1548 in the amount of $500 for the date of 12/19/2023 is assessed for a violation that the department determines was a fire clearance violation.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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


Document Has Been Signed on 12/19/2023 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #3
FACILITY NUMBER: 342700878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility did not ensure that fire exits were unobstructed and carbon monoxide detectors were installed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Facility will ensure that evacuation exits are clear of clutter and debris and are unobstructed. Facility will install carbon monoxide detectors. LPA will return to facility on a future date to clear deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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