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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 09/07/2023
Date Signed: 09/12/2023 05:13:16 PM

Document Has Been Signed on 09/12/2023 05:13 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:
09/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Cindy Lichetenhan, Exective DirectorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 09/07/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility to follow up on deficiencies observed the previous day. The LPA identified herself, the purpose of the visit and met with the Designated Facility Administrator. A brief interview followed.

During a tour of Memory Care on 09/06/23, this LPA observed a 5 inch pair of scissors in an unlocked drawer of the bathroom of a resident in care. This LPA also observed 10 toxic hygiene items amongst three rooms. These items included but were not limited to: Pantene shampoo and conditioner, Jergens Hydrating Coconut moisturizer, Neutragena shower gel, and CalProtect ointment. The doors to these rooms were wide open and there were no residents present at the time as they were having lunch.

LPA discussed the seriousness of having these items accessible to residents in care without supervision. Even if the resident who is assigned that room is allowed access to hygiene products per their LIC 602, the door to the room must be locked and secured. As Memory Care residents often do not remember to do this, these items must be made inaccessible in order to keep everyone safe from harm.

These deficiencies were cited on the LIC 809 D page.

A copy of this report was provided along with Appeal Rights.

An exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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 09/12/2023 05:13 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/07/2023 at 05:13 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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87705(f)(1)

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Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
The Licensee did not comply with the section above when:
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Licensee conducted an in-service the same day the violation was observed. Licensee shall submit a sign-in sheet to kimberly.viarella@dss.ca.gov by 09/08/23 from that in-service.
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Based on observation this LPA observed a 5 inch pair of scissors in an unlocked drawer in a memory care resident's open room.
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Type A
09/08/2023
Section Cited
CCR87705(B)(2)

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Care of Persons with Dementia
(b) In addition to the requirements as specified...(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. The Licensee failed to comply with the above regulation when:
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Licensee shall have MedTechs do sweepsfor restricted/toxic items in Memory Cre resident rooms on a daily basis. Licensee will submit schedule of sweeps to kimberly.viarela@dss.ca.gov by 09/08/23.
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Based on observation, this LPA observed 10 toxic hygiene items amongst 3 open resident rooms. These items included but were not limited to: Pantene shampoo and conditioner, Jergens Hydrating Coconut moisturizer, Neutragena shower gel, and CalProtect ointment.
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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: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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