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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700333
Report Date: 08/19/2020
Date Signed: 08/19/2020 02:15:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FAIR OAKS ESTATES INCFACILITY NUMBER:
342700333
ADMINISTRATOR:SAROAY, PARVEENFACILITY TYPE:
740
ADDRESS:8845 FAIR OAKS BLVDTELEPHONE:
(916) 944-2077
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:106CENSUS: 80DATE:
08/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Executive Director, Parveen SaroayTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Llopis contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 08/19/2020. LPA spoke with Executive Director, Parveen Saroay and explained the purpose of the call was to discuss an incident involving a resident (R1) in care who recently passed on 07/26/2020.

LPA interviewed ED and requested the following documents for Department review:

Incident report for the fall on 07/17/2020 and R1's death report on 07/26/2020.

No deficiencies are being cited as a result of today's call.

Exit interview conducted via telephone with Executive Director. Copy of report provided to the facility. The facility will print, sign and email a copy of the report back to CCL.


SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
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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