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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700333
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:19:39 PM


Document Has Been Signed on 04/19/2022 01:19 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:FAIR OAKS ESTATES INCFACILITY NUMBER:
342700333
ADMINISTRATOR:SINGH, GURSHAHBAZFACILITY TYPE:
740
ADDRESS:8845 FAIR OAKS BLVDTELEPHONE:
(916) 944-2077
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:106CENSUS: 76DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Shahbaz Singh, Executive Director TIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Shahbaz Singh, Executive Director and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask. The facility currently has (8) residents receiving hospice services.

LPA and Executive Director toured the interior and exterior of the facility of both the Assisted Living Unit and the Memory Care Unit to ensure the health and safety of residents in care. Areas toured include, but are not limited to: common areas, resident bedrooms, bathrooms, staff break room, medication rooms, shower rooms, salon and laundry rooms. Facility has (31) shared resident rooms and some are singly occupied currently. 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 compliance at this time. Inside temperature was observed to be 73* F. Fire extinguishers (2+) were last serviced 2/9/2022, and LPA observed fire doors to be open as required. LPA observed Covid posters throughout -facility will post additional posters showing (12) symptoms of Covid and 20-second hand-washing at every sink and also ensure all trash cans have a lid in restrooms. LPA observed medications, toxins and sharps to be locked. Resident and staffing vaccination status was discussed as well as current requirements for weekly testing. LPA observed documentation of staff exemptions and weekly testing on file. Current visitor protocols also discussed per PIN 22-07. Discussed recommendations made at last annual in Oct 2021.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report to be emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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