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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:02:31 PM

Document Has Been Signed on 11/30/2023 12:02 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 59DATE:
11/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Teri FordTIME COMPLETED:
12:20 PM
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On 11/30/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of today's visit.

Grounds
The grounds were observed to be maintained and all paths were free of obstruction. The facility maintains adequate outdoor furniture. There are shaded areas for the clients to enjoy outdoor activities. The facility maintains outdoor water fountains that have determined to be in compliance.

Physical Plant
The physical plant was observed to be sanitary and free of odor. The facility temperature was 77 degrees for the comfort of the residents which falls between the required regulatory range of 68-85 degrees Fahrenheit. The fire extinguisher was last serviced in August of 2023 and is in compliance. The smoke detectors and carbon monoxide detectors were observed to be in good working order. The disaster plan was reviewed and is in compliance. The facility furniture and equipment were determined to be in good repair. The common area bathrooms were observed to have open top waste disposal cans. Technical assistance was provided. LPA Jensen toured 6 resident rooms. LPA Jensen observed numerous of bottles of prescription medications, PRN medications and cleaning chemicals such as bleach stored with food throughout the living area for resident 2 (R2). LPA Jensen reviewed the physician's report for R2 and confirmed that R2 is responsible for their own medication administration however the facility is taking no precautions in order to secure the medications and toxins from other residents with restrictions that can freely enter the room. Technical assistance was provided. LPA Jensen tested the water temperature in resident rooms and observed the temperature to range between 106 and 108 degrees Fahrenheit which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains an adequate supply of linens. The resident units are adequately furnished with beds, night stands, dresser and lamps.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 11/30/2023
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Physical Plant
LPA Jensen observed the elevators to be in good working order. The facility maintains an evacuation chair at the stair well. All required postings were observed in the correct format and size. LPA Jensen observed a variety of activities available for client engagement including but not limited a full exercise gym, poker tables, shuffle board tables.

LPA Jensen toured the kitchen and the dining area. LPA Jensen observed the refrigerator and freezer temperatures to be in compliance. The Ansul system was last served in August of 2023 and is in compliance. There was a 7 day supply of non-perishable food and 2 day supply of perishable food available. LPA Jensen observed lunch service. The facility menu stated that lunch service would consist of a choice between white wine and mushroom chicken or hamburger steak and onions, salad, cheesy mashed potatoes, baked roll, green beans and blonde brownies with nuts. The facility did not have potatoes on hand and made an impromptu substitution with mashed sweet potatoes. Technical assistance was provided.

Medication
LPA Jensen inspected the medication room in the memory care unit and interviewed a medication technician, staff 1 (S1) and the Resident Care Director, staff 2 (S2). LPA Jensen reviewed medication for resident 3 (R3) and resident 4 (R4). 2 of 2 residents had a medication count under the amount reflected on the Medication Administration Record (MAR). LPA Jensen interviewed S1 and S2 regarding the discrepancy. S1 indicated the facility received the wrong amount of medication from the pharmacy and S2 was unable to explain the discrepancy. The Health and Wellness Director was notified of the discrepancy and she was able to show LPA Jensen that according to the Centrally Stored Medication and Destruction Record (CSMDR) the 2 residents were admitted to the facility with partial prescriptions and all medication was accounted for. In addition, the facility utilizes an electronic Medication Administration Record (MAR). Technical assistance was provided.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 11/30/2023
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File Reviews
On 11/21/23, LPA Pascua reviewed 7 staff files. 7 of 7 staff files were either missing first aid certifications or the certification was expired. LPA Pascua reviewed 12 resident files, 7 from memory care and 5 from assisted living. 11 of 12 resident files had service need assessments that were either missing or incomplete due to missing signatures. 2 of 12 resident files did not have current Physician Reports. 4 of 11 files did not have a completed property inventory list.

LPA Jensen conducted interviews with 3 staff members and 3 residents. Residents interviewed expressed satisfaction with quality of care. Staff interviews revealed opportunity for training enhancement.

LPA Jensen requested current copies of:
The infection control plan
LIC 500
LIC 308
Liability Insurance

The documents will be emailed by 12/6/23

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) and/or Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 12:02 PM - It Cannot Be Edited


Created By: Maja Jensen On 11/29/2023 at 04:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87411(c)(1)

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Personnel Requirements - General
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met based on:
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The Director agrees to send an attestation to maja.jensen@dss.ca.gov that all staff will be enrolled in and complete first aid training by 01/15/24.
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 LPA Pascua's review of 7 staff files, 7 of 7 files were missing first aid certificates or had expired first aid certificates. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type A
12/01/2023
Section Cited
CCR87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident...This requirement was not met as evidenced by:
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The Director agrees to send an attestation to maja.jensen@dss.ca.gov that all resident records will be updated and complete by 01/15/24
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Based on LPA Pascua's resident record review 11 out of 12 resident records were incomplete to a varying degree-please refer to LIC 809C for specifics. This poses an immediate risk to the health, safety and personal rights of reisdents 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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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