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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 09/30/2024
Date Signed: 11/06/2024 10:01:31 AM

Document Has Been Signed on 11/06/2024 10:01 AM - 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/
DIRECTOR:		CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 72CENSUS: DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Teri FordTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 9/30/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with the Director of Health ad Wellness and explained the purpose of today's visit.

LPA Jensen toured the exterior and observed all paths to be free of obstruction. The facility property also has independent living suites on site and a swimming pool. The swimming pool was area was verified to be locked. There are shaded areas and outdoor furniture available for resident use. The facility has numerous activities available for resident engagement. An independent living suite was toured.

LPA Jensen toured the interior of the facility including the dining room, hair salon, gym and several gathering areas. The common areas contained adequate furniture and lighting. The kitchen was observed to have a 2 day supply of perishable food and a 7 day supply of non-perishable food. The lunch service accurately reflected what was listed on the menu. The fire extinguisher and Ansul system was last serviced in August of 2024 and is in compliance. The stairways are equipped with evacuation chairs. LPA Jensen toured the resident rooms in assisted living and memory care. LPA Jensen observed a cabinet that had a pillow with a plastic covering that had writing which said for use to cover incontinence stains on upholstered chair. The chair in the room was observed to be stained. LPA Jensen tested the call signal system and care staff responded in a timely manner.

The facility currently has 8 residents on hospice. Hospice care plans were on file for all 8 residents. A signed agreement was observed to be on file for a resident sharing a room with a resident on hospice. LPA Jensen conducted interviews with staff members and residents. LPA Jensen reviewed 5 resident files. The physician's report was outdated in 2 of 5 files. Furthermore, the needs and service plans did not accurately reflect the needs of 2 of residents. The facility has 2 residents that have insulin dependent diabetes.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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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: 09/30/2024
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1 of 2 residents that has insulin dependent diabetes has a physician report that makes no mention of this condition. The second resident with insulin dependent diabetes has a physician order stating they are unable to handle their own injections. Both residents with diabetes have a needs and service plan that says med techs will assist with insulin administration. 2 of 5 residents files showed multiple documented falls resulting in serious injury yet no fall mitigation plans put in to place. Deficiencies are being cited and technical assistance is being provided. Failure to correct deficiencies may result in the assessment of civil penalties.

LPA Jensen reviewed 4 staff files and found them to be complete with 1st aid certifications, all required training documented, criminal background clearance and health screens.

LPA Jensen is requesting the facility provide the following by 10/7/24:
Liability insurance
LIC 500
Dementia Care Plan
Diabetes Care Plan
Incontinence Care Plan

The facility has an infection control plan and a disaster plan readily available.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 10:01 AM - It Cannot Be Edited


Created By: Maja Jensen On 09/30/2024 at 04:46 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: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's record review, a resident with diabetes did not have the required documentationto reflect this condition. As such LPA Jensen was unable to determine oif the resident is able to handle their own injections and glucose testing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The licensee will update all resident records needed to reflect R1's diabetes. A new physician report will be emailed to teh LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's resdient record review 2 of 5 residents did not have a current physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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The Licensee will ensure all residents have a current LIC 602 and will email the LPA once complete.
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: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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