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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700821
Report Date: 05/31/2023
Date Signed: 05/31/2023 12:33:31 PM

Document Has Been Signed on 05/31/2023 12:33 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:BLUEBERRY HILL SENIOR LIVING, INC.FACILITY NUMBER:
342700821
ADMINISTRATOR:HAMRIC, KEITHFACILITY TYPE:
740
ADDRESS:3827 OLIVE LANETELEPHONE:
(916) 900-8399
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
05/31/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Megan HamricTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a case management visit to complete the annual inspection conducted on 5/17/2023. LPA met with Licensee, Megan Hamric, and explained the purpose of the visit.

During today's visit, LPA observed caregiver serving lunch to residents in care. LPA and Licensee continued and completed the full CARE tool kit during today's visit. Facility was found to be in compliance. No deficiency was cited as a result of today's inspection.

Additionally, LPA requested a copy of Administrator Certificate, liability insurance, LIC 500 and LIC 308 to be emailed to LPA Yang by Wednesday June 7, 2023. Licensee provided a copy of Administrator Certificate and certificate of liability insurance. Licensee will email LIC 500 and LIC 308.

Exit interview conducted with licensee and a copy of the report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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