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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701207
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:49:34 PM

Document Has Been Signed on 10/29/2025 03:49 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/
DIRECTOR:
LACY VINCENTFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 114CENSUS: 77DATE:
10/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:46 AM
MET WITH:Kurtis Woody, Health & Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 10/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by a staff member. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. The Health and Wellness Director/acting Administrator Kurtis Woody was on-site (Administrator Certificate #6073581740, expiration date 01/03/2026), and an interview followed. The Administrator accompanied the LPA on a tour of the interior and exterior of the physical plant. The CARE inspection tool was used during this inspection.

The facility includes Assisted Living, Memory Care, and Independent Living units. The licensed one-story Memory Care unit is located across a paved walkway from the two-story Assisted Living unit. The facility is licensed for a capacity of 114 residents, including 23 ambulatory and 77 non-ambulatory, of which 14 can be bedridden. It had a hospice waiver for 7. At the time of the site visit, the census was 77 residents, including 24 in Memory Care and 53 in Assisted Living.

The LPA inspected the physical plant, including but not limited to the dining areas, kitchens, storage rooms, activity rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. The Facility License, Complaint Hotline Poster, Ombudsman information, menus, and activity calendars were publicly posted.

The LPA toured the kitchen and interviewed the Kitchen Manager. The entire kitchen, including its appliances, working surfaces, floor, and storage areas were clean, sanitary, and odor-free. The LPA observed a two-day supply of perishable food and seven-day supply of non-perishable food, located in upright freezers and refrigerators, storage rooms, and a walk-in refrigerator/freezer. Food was properly

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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: 10/29/2025
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stored, and safe food storage guidelines were prominently displayed on the wall. Daily cleaning schedules for the AM and PM shifts were posted. Refrigerator/freezer temperature logs and food temperature logs were posted in visible locations and actively used daily. Appliances were in working order. The stove hood was clean and last serviced by IC Refrigeration in June 2025.

The LPA observed lunch service. Food portions were adequate, and the meal contained a variety of food types. Daily menus were located on each table. The LPA observed residents eating and socializing.

The LPA toured common areas intended for resident use, including hallways, theater, game room, gym, and bistro. These areas were decorated, clean and odor-free. They had adequate furnishings and lighting in good repair and working order. The thermostat was set at 76 degrees Fahrenheit. There was an evacuation chair at the top of each staircase and evacuation maps posted throughout the facility. The elevator was last inspected on 3/6/2025. The facility had an Ansul fire suppression system that included sprinklers and pull alarms; it was last serviced by Imfeld Cloutier Fire Protection on 7/28/2025. The fire extinguishers were last serviced by the same company on 7/23/2025. Chemicals were properly stored in locked housekeeping storage rooms. There were smoke and carbon monoxide detectors in working order in resident rooms and hallways. In the Memory Care unit, the LPA exited the building through a side door. The alarm sounded immediately and a staff responded to the alarm within a minute.

The LPA observed ten residents’ living quarters. The resident apartments were clean and odor-free. Apartment units contained the required furnishings, and each was personalized with residents’ own belongings. The windows were in good repair and there were large closets for storage. The bathrooms contained working water fixtures, sturdy grab bars, and non-slip flooring. The LPA measured the temperature of the hot water in two resident bathroom sinks. The hot water was 108 degrees Fahrenheit, which was within the required regulation of 105 to 120 degrees Fahrenheit. While in a resident room, the LPA pushed the call button. Staff responded within three minutes.

The LPA toured the outside areas. Walkways were flat, smooth, and free from obstruction. The grounds were manicured and decoratively planted. Interior courtyards in both the Memory Care and Assisted Living units contained seating and shaded areas for residents.

Due to time constraints this required 1 year annual will be continued at a later date. An exit interview was conducted with the Memory Care Director and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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