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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920137
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:17:48 PM


Document Has Been Signed on 09/17/2024 12:17 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:SPLENDOR OF CARMICHAEL AT KEANE, LLC, THEFACILITY NUMBER:
345920137
ADMINISTRATOR:VO, LUIGIFACILITY TYPE:
740
ADDRESS:4921 KEANE DRTELEPHONE:
(916) 550-2908
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Luigi Vo, Applicant/AdministratorTIME COMPLETED:
11:00 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Luigi Vo, Applicant/Administrator
Interview Method: Telephone interview

On September 17, 2024 at 10:10 AM, Applicant/Administrator participated in COMP II. Identification of the Applicant/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. S

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program.
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant/Administrator. Report sent via email and request to return sign copy to CAB by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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