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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 08/23/2023
Date Signed: 08/23/2023 06:59:44 PM

Document Has Been Signed on 08/23/2023 06:59 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 57DATE:
08/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:23 PM
MET WITH:Terri FordTIME COMPLETED:
06:15 PM
NARRATIVE
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On 08/23/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a resident on resident altercation that involved 3 individuals on 08/20/2023 at 3:45 AM. The LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. Staff called Terri Ford who agreed to speak with the LPA over the phone and have a designee sign on her behalf.

Although this incident took place on 08/20/2023, Licensing did not receive an LIC 624 until 08/23/2023. This is in violation of reporting requirements. Whenever there is an incident of assault or abuse Licensing must receive a faxed LIC 624 and an SOC 341 within 24 hours. If for some reason a fax cannot be sent, then the Licensee should call the main office and ask to speak with the LPA/worker of the Day.

According to California Code or Regulations, Title 22 Division 6, a deficiency has been observed and cited on the LIC 809 D page.

A copy of this report was provided along with Appeal Rights to the Designee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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 08/23/2023 06:59 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 08/23/2023 at 06:27 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
87211(a)(2)

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Reporting Requirements
(a) Each licensee shall furnish... reports as the Department may require... (2) Occurrences, such as ... safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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The Licensee shall conduct a training on reporting requirements and submit an outline of the training and a participant signature sheet to kimberly.viarella@dss.ca.gov by 09/20/2023.
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This regulation was not met when the Department did not receive a fax or phone call to the LPA/Worker of the Day with the details of the altercation. An SOC 341 should also have been completed for cross reporting purposes.
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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:Liza King
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
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