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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:52:03 PM

Document Has Been Signed on 09/06/2023 03:52 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:
09/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Cindy LichtenhanTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Viarella conducted an unannounced case management incident visit. Community Care Licensing received an incident report indicating that resident #1 (R1) was Absent without Leave (AWOL). This occurred on 08/27/2023. (This information was incorrectly reported on the initial SOC341 as the tie was just past midnight. LPA met with administrator and explained purpose of the visit.

LPA interviewed the Administrator regarding the absence of R1. R1 left facility on August 27, 2023 at approximately 12:01 AM by exiting the back door by the salon. The resident walked to Circle K across the street where Oakdale Police were called by a Circle K employee. Police called Belmare at approximately 12:30 AM asking if they had a resident, R1. A Med Tech, M1, went to pick up the resident. The staff on duty had no knowledge of the (AWOL) until police contacted the Administrator. Upon LPA review of the most recent Physician Report (LIC 602) dated 10/12/2022, it indicated that R1 was not able to leave the facility unassisted.

The facility has since installed cameras that the MedTechs can view on their laptops when the alert sounds.

Per California Code of Regulations California Health and Safety Code - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. If the following cited deficiency is not corrected by the noted due date; additional civil penalties may be assessed.
Immediate Civil Penalty of $500.00 cited.

An exit interview was conducted with Administrator. A copy of this report, LIC 811 (Confidential Names), and appeal rights were left at the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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 09/06/2023 03:52 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/06/2023 at 02:46 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: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
HSC
1569.312(d)

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HSC - 1569.312(d) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by:
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Licensee agrees to conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 09/08/23 via email to LPA Kim Viarella. Proof of staff training for the cited section will be completed and a signature sheet of all staff who attended will be submitted to LPA Kim Viarella after training is finished.
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Based on incident report, the facility did not comply with section cited above in 1569.312(d). R1 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.
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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: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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