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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700764
Report Date: 05/16/2022
Date Signed: 05/16/2022 11:49:31 AM

Document Has Been Signed on 05/16/2022 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 2FACILITY NUMBER:
312700764
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:6056 BIG BEND DRTELEPHONE:
(916) 297-7141
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:caregiver, Ashanti InnisTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 5/16/22 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: n-95 mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unable to attend.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 resident bedrooms, 3 bathroom, kitchen, laundry room, and backyard. LPA and caregiver completed the infection control domain.

LPA measured the water temperature in the residents' bathroom/ shower to be 124 degrees F. Temperature was adjusted while LPA present. LPA found cleaning supplies unsecured in the garage and advised that the cabinets with locks be utilized.
LPA advised that records or daily symptom screening of residents and staff as well as weekly testing of staff not vaccinated and boosted be maintained and available at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 2
FACILITY NUMBER: 312700764
VISIT DATE: 05/16/2022
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LPA requested that the following records be submitted: Liability Insurance declaration, Resident roster, staff roster, proof of screening, covid testing (if applicable) and LIC 308.

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.

Exit interview conducted and copy of report and appeal rights left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2022 11:49 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 05/16/2022 at 11:28 AM
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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 2
FACILITY NUMBER: 312700764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303e(2)
Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the resident shower room sink had a temperature of 124' F. as measured by LPA thermometer at approximately 11 AM which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Caregiver adjusted water temperature while LPA was present yet temperature had no sufficiently reduced.

Licnesee will submit records of temperature readings taken 5/16/22 Pm and 5/17/22 am for POC date of 5/17/22.
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 Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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