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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 03/08/2023
Date Signed: 04/28/2023 05:07:49 PM

Document Has Been Signed on 04/28/2023 05:07 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:GONZALEZ, SONYAFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
2097643164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 72CENSUS: 40DATE:
03/08/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sonja GonzalezTIME COMPLETED:
04:00 PM
NARRATIVE
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Unannounced post-licensing visit conducted by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang on 03/08/2023. LPAs identified themselves and the purpose of their visit to the staff and instructed them to notify the Administrator, Sonja Gonzales, of their arrival. While waiting, LPAs interviewed a resident sitting in the lobby area who stated she was very happy with her experiences at Belmare Senior Living. When Administrator Gonzales joined the LPAs, they interviewed her briefly.
Census was currently 40 with 2 being on hospice and 1 bedridden. She then went on to demonstrate the computerized system for checking in visitors. Name badges were made and temperatures were taken.
The tour began with resident accommodations. Rooms were clean and had adequate furniture and lighting. Each room had a private bathroom where grab bars and no-skid shower surfaces were observed. The water temperature was measured to ensure it was between 105 and 120 degrees.
LPAs observed smoke and carbon monoxide detectors throughout the facility and fire extinguishers were last inspected in January of 2023.
The kitchen was inaccessible to residents and clean and sanitary. The LPAs observed 7 days of non-perishable and 2 days of perishable food supplies. The facility chef was interviewed and she informed the LPAs that supplies were delivered twice a week.
LPAs toured the medication room. Policies and procedures were discussed and the EMAR system and logs were reviewed. Medications, including narcotics, were kept in a locked cart and distributed to residents on an individual basis as directed by their physicians.
The laundry and housekeeping rooms were kept locked and were inaccessible to residents.
At this time there were 7 residents in the memory care corridor of this facility.
LPAs observed an operational delayed egress. The memory care area contained a kitchenette where snacks were stored. LPAs inspected all cabinets and drawers.
Common areas were toured as well. Storage areas were inspected.
LPAs pulled an emergency cord in a resident room and the response time was 5 minutes and 40 seconds.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 03/08/2023
NARRATIVE
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The following deficiencies were observed and cited on the 809 D.

Appeal Rights were printed and a copy was given to the designated facility administrator at the time.

Exit interview.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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Document Has Been Signed on 04/28/2023 05:07 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 03/08/2023 at 03:54 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: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation of a water temperature measurement of 125 degrees, made by the LPA, the the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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The water temperature was lowered while LPAs were still on the premises. No further POC required.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation of the LPAs, the licensee did not comply with this regulation and cleaning solutions were found in areas accessible to the residents which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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Cleaning solutions were removed and stored immediately and no longer pose a hazard or risk to residents. No furhter POC required.
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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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