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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700333
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:26:12 AM


Document Has Been Signed on 02/10/2023 10:26 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: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: 103DATE:
02/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rhonda Carter, business managerTIME COMPLETED:
10:30 AM
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On 2/10/23, Licensing Program Analyst (LPA), Kevin Mknelly, arrived unannounced and met with the business manager. Prior to the visit, LPA followed the department's Covid 19 protocols, was symptom free, hand sanitized and wore a surgical mask. LPA was screened at the facility.

The purpose of the visit was to deliver a ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY for S1. The order was received by the business manager.

No deficiencies were noted during the visit.
Report was reviewed and copy left with the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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