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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:01:42 PM

Document Has Been Signed on 01/25/2024 04:01 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: 65DATE:
01/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Teri FordTIME COMPLETED:
04:10 PM
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On 1/25/24 at approximately 3:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a case management. LPA Jensen met Executive Wellness Director Teri Ford and explained the purpose of today's visit.

On 1/5/24 Teri Ford emailed an inquiry to LPA Jensen regarding acceptance of resident with a potentially restricted/prohibited condition who was returning from a skilled nursing facility with a higher level of care needed. LPA Jensen provided technical assistance in the areas of restricted health conditions, prohibited health conditions and indwelling urinary catheters.

No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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