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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700196
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:46:48 AM


Document Has Been Signed on 11/17/2022 11:46 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:HAZEL PARK SENIOR CAREFACILITY NUMBER:
342700196
ADMINISTRATOR:HILDEBRANDT, CHI-WENFACILITY TYPE:
740
ADDRESS:7540 HAZEL AVENUETELEPHONE:
(916) 988-2122
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Chi-Wen Hildebrandt, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/17/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Chi-Wen Hildebrandt, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA confirmed that facility does not any positive covid-19 cases and nobody is experiencing any covid-19 symptoms today before facility entry. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility staff upon entry.

LPA and administrator toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 5 bedrooms and 3 bathrooms for residents, common area, dining room, kitchen, garage, laundry room, outdoor area, and storage. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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