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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700708
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:16:05 PM

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 HOME FOR SENIORSFACILITY NUMBER:
342700708
ADMINISTRATOR:PEREIRA,JULIEFACILITY TYPE:
740
ADDRESS:4919 HAZEL AVETELEPHONE:
(831) 334-1223
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 2DATE:
07/02/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Julie Pereira, LicenseeTIME COMPLETED:
02:00 PM
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An office meeting was held today, 7/2/2021, via face-time Microsoft Teams meeting due to COVID-19 and precautionary measures. The purpose of today's meeting was to address the facility's intent to change ownership but remain open as a licensed care facility.

The following Licensing staff were present:
Troy Ordonez and Michael Hood

The following representatives were present:
Licensee, Julie Pereira

The following topics were covered during today's meeting:
  • Eviction Notices for change of ownership
  • Leaseback agreement while new Licensee completes the application process for change of ownership
  • Scenarios and potential resolutions if new applicant is unable to be licensed


Licensing Program Analyst (LPA) Michael Hood will follow-up with Licensee to obtain a copy of the eviction notices and leaseback agreement.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to CCL.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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