<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:53:02 AM

Document Has Been Signed on 11/04/2022 11:53 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:GONZALEZ, SONYAFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(360) 882-4500
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 72CENSUS: 0DATE:
11/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sonya Gonzalez, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tung Truong arrived at this facility announced on 11/4/2022 at 10:00 AM to conduct a pre-licensing inspection. LPA met with the facility designated Administrator Sonya Gonzalez and explained the purpose of the visit. The facility designated Administrator Sonya Gonzalez assisted with today’s visit.

Administrator Sonya Gonzalez holds a current certificate # 6034581740 which will expire on 04/14/2023. LPA toured and inspected the physical plant inside and outside with the administrator Sonya Gonzalez to ensure there were no health and safety concerns on 11/4/2022 at 10:30 AM. LPA observed there were no residents in care at this time.

The facility had Covid-19 posting throughout the facility. The facility had an infection control plan completed and was last reviewed on 5/4/2022. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. The theater, art studio, and fitness room were reviewed to make sure that all components were functional and in good repair at this time.



Continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 11/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review was conducted of the apartment sizes and different layouts. The med rooms, located primarily on the first floor, was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 109.5*F during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility observed at 70*F which was within the required range of 68-85*F.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kits were available in the kitchen and med rooms. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPA observed the area where the staff and resident files were locked and readily available for review.

Based on a review of this facility during this Prelicensing visit, it was determined that this facility was found to be in compliance at this time. LPA discovered that the facility designated Administrator Sonya Gonzalez has completed Component III before and will therefore waive this requirement.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2