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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700761
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:17:41 PM

Document Has Been Signed on 10/26/2021 03:17 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 1FACILITY NUMBER:
342700761
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:3609 VOLEYN STTELEPHONE:
(916) 993-9921
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Dacia Dacosta, caregiver TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA confirmed there are no residents or staff with a confirmed case or signs/symptoms or Covid. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed all (4) residents in the common area ot the facility and (1) resident is on hospice. LPA spoke with Sorina and Maria, managers, who was not able to be at the facility during the inspection.

LPA and caregiver Dacia toured the interior of the facility including (6) private bedrooms and half bathrooms, (3) full bathrooms, laundry area, garage, and kitchen. LPA observed it to be clean and in good repair. LPA observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and caregiver completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap and sanitizer and hand-washing poster in the bathrooms. Recommended trash cans with lids in each bathroom. Discussed vaccination status of residents and staff.

There were no deficiencies observed during today's inspection. LPA requested updated copy of liability insurance and Administrator Certification.

Exit interview with Maria, manager, by phone. Copy of report signed by caregiver and to be e-mailed to facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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