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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:27:55 PM

Document Has Been Signed on 09/21/2023 03:27 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 72CENSUS: 57DATE:
09/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Terri FordTIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/21 23 at approximately Licensing Program Analysts (LPA Maja Jensen and Kimberly Viarella arrived unannounced to conduct a case management in relation to an incident report received by the Department on 9/17/23. LPA Jensen and Viarella met with Health and Wellness Director Terri Ford and explained the purpose of today's visit.

The incident report received stated that Resident 1 (R1) left the facility unassisted and without staffs knowledge on 9/16/23. LPA Jensen conducted an interview with the Health and Wellness Director and was advised that in the morning on 9/16/23 staff did rounds at approximately 7am and R1 was observed in her room. At 7:45am staff went to R1's room and could not locate her. Staff reviewed video footage for the main entrance of the facility and saw R1 leave through the front door at 7:31am. At approximately 8:15am the resident was located by a family member and brought back to the facility. LPA Jensen was also advised that R1 had a previous elopement approximately 2 months prior to the incident of 9/16/23. On 9/17/23 R1 was moved from the assisted living section of the facility to the memory care unit.

LPA Jensen reviewed the LIC 624 (Unusual Incident/Injury Report) and the LIC 602 (Physician's report). The LIC 602 indicates that the resident cannot leave the facility unassisted.

Citations are being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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Document Has Been Signed on 09/21/2023 03:27 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/21/2023 at 02:30 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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87464(f)(1)

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Basic Services
Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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The facility moved the resident to memory care the following day and scheduled an appointment for a new LIC 602. No additional plan of correction is required at this time.
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Based on the incident report provided and the interview conducted with the Health and Wellness director, R1 left the facility without the knowledge of staff which poses an immediate risk to the health, safety and personal rights of residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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