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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701207
Report Date:
07/05/2024
Date Signed:
07/05/2024 04:01:31 PM
Document Has Been Signed on
07/05/2024 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 LIVING
FACILITY NUMBER:
502701207
ADMINISTRATOR/
DIRECTOR:
CINDY LICHTENHAN
FACILITY TYPE:
740
ADDRESS:
1450 WEST F STREET
TELEPHONE:
(209) 764-3164
CITY:
OAKDALE
STATE:
CA
ZIP CODE:
95361
CAPACITY:
72
CENSUS:
72
DATE:
07/05/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:
Teri Ford
TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 7/5/24 Licensing Program Analyst (LPA) Maja Jensen arrived unannounced at facility to conduct a complaint investigation. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of the visit.
During the course of the investigation LPA Jensen reviewed the file for resident 1 (R1). There were 2 LIC 602's in file both from February of 2023. LPA Jensen interviewed the Health and Wellness Director who stated that R1 has been determined to have a systemic health condition that has resulted in a recurring skin condition. Both LIC 602's state the resident has no history of skin conditions. Technical assistance is being provided to ensure that residents receive an updated physician's report at least every 12 months or whenever a change in condition is identified.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/05/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/05/2024
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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