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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005251
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:34:13 PM


Document Has Been Signed on 06/28/2023 03:34 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:ATRIA CARMICHAEL OAKSFACILITY NUMBER:
347005251
ADMINISTRATOR:HAGEN, KIMBERLYFACILITY TYPE:
740
ADDRESS:8350 FAIR OAKS BLVDTELEPHONE:
(916) 944-2323
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:95CENSUS: 70DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kimberley HagenTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Mknelly and Jaynae Boyles arrived at the facility unannounced on 6/28/23 to conduct a Required-1 Year Inspection utilizing CARE inspection tool. LPA met with the Executive Director and explained the purpose of the visit.

LPA toured the interior of the facility together with Executive Director and maintenance director to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms as well as the rest of the physical plant. In the areas toured no immediate health, safety, or personal rights violations were observed. The residence was found to be clean, safe, sanitary and in good condition. Water temperature logs were checked and water maintained in required range.
Facility has required food supplies. There are appropriate staff present to meet the needs of residents.

The licensee was found to have two (2) residents who are non-ambulatory residing on the third floor in violation of the fire clearance.

LPA reviewed resident files and staff files. 7 Resident files reviewed are complete and current. 7 Staff files reviewed were complete- training is ongoing.

LPA requested licensee submit a copy of liability insurance.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.Report reviewed with Kimberly Hagen . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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 06/28/2023 03:34 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: ATRIA CARMICHAEL OAKS
FACILITY NUMBER: 347005251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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 observation and records review, the licensee did not comply with the section cited above in 2 residents, R1 and R3, with non-ambulatory diagnosis resided on the third floor which has a fire clearance for ambulatory only.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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Licensee arranged for the two residents to move to an appropriate floor. Licensee will review all residents on the third floor to insure no further violations.
This citation is cleared today as correctios were made.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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