502701207-6-9-2025-27-AS-ELIM-DHGU9Z-20250609152358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 06/09/2025
Date Signed: 06/09/2025 03:24:12 PM

Document Has Been Signed on 06/09/2025 03:24 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: 114		CENSUS: 95	DATE:	06/09/2025
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Lacy Vincent, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/9/2025, Licensing Program Analysts (LPAs) Triel Ellen Lindstrom and Arielle Pascua arrived announced for a case management visit to tour the Memory Care unit. The facility has requested an increase in their capacity from five to fourteen bedridden residents. The Department has received the facility's updated Plan of Operations, which incorporates the required language about dementia care, a signed LIC 200, a completed STD 850, and a new facility sketch that designates bedridden rooms. The LPAs met with Designated Facility Administrator (DFA) Lacy Vincent, who gave them a tour of the new Memory Care unit. On the tour of the Memory Care unit, the LPAs viewed the common areas, two resident bedrooms, two laundry rooms, a storage area, the kitchenette, the reception area, two interior courtyards, and an enclosed outside paved walkway and garden. The current capacity of the unit is 22 residents. The unit is clean and the rooms contain the required furnishings. The LPAs observed residents gathered around a large table with the Activity Director and her assistant doing a painting project. The outdoor area with a walkway is located in the front of the building between it and the parking lot. It is enclosed with a tall metal perimeter fence. The gate leading out of this area is currently unlocked. Because of this, residents are accompanied one-on-one with a caregiver when in this area. A technician has been scheduled to install a delayed egress on the gate in mid-June. The new Memory Care unit contains six rooms that have been cleared for bedridden residents. These six rooms are Rooms # 501, 504, 505, 520, 524, and 525. These rooms are identical to every other room in the unit. The rooms designated as bedridden rooms on the new facility sketch are all located near the corners of hallways. DFA Vincent stated that this location will make it easier for staff to evacuate residents in the case of

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/09/2025

NARRATIVE

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an emergency, as there is an exit door at each corner. The unit has an approved capacity of forty-two residents. DFA Vincent stated that she recently sent a revised occupancy plan to management, reducing the number of rooms designated for double occupancy from sixteen to eight. This would cap the total occupancy at thirty-six residents maximum.

This site visit concludes the Department's approval of the six new bedridden rooms in the facility's Memory Care Unit, increasing the capacity from five to fourteen bedridden residents in the facility.

Based on observation and records review made during this site visit, there were no deficiencies observed or cited during today's case management visit.

A brief exit interview was conducted with DFA Vincent and a copy of this report was provided to the DFA.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

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