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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700708
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:38:51 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: 3DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Leah Cunningham, CaregiverTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the facility unannounced on 8/20/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with caregiver and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPAs were screened by staff upon entry and signed visitor log with temperatures.

LPA Angela Hood spoke to the Administrator, Julie Pereira, by phone and Julie stated that caregiver can sign report.

LPAs toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 3 bathroom for residents, common area, dining room, kitchen, and outdoor area. LPA and Administrator completed the infection control domain by phone and facility was found to be in compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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