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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:14:54 PM


Document Has Been Signed on 11/21/2023 04:14 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:72CENSUS: 58DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cindy LichtenhanTIME COMPLETED:
04:30 PM
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On 11/21/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Arielle Pascua arrived at facility unannounced to conduct a required 1 year annual. LPAs Jensen and Pascua met with Executive Director Cindy Lichtenhan and explained the purpose of today's visit.

During the course of the visit LPA's Jensen and Pascua toured the interior of the facility including common areas, bathrooms, kitchen and 6 resident rooms. LPAs reviewed 10 resident files and 7 staff files. 2 staff members and 2 residents were interviewed. A random audit of the medication room was conducted. The inspection tool was used during this visit.

Due to time constraints this required 1 year annual will be continued at a later date. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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