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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 04:37:19 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:Post LicensingUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Leah Cunningham, CaregiverTIME COMPLETED:
03:35 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the caregiver to conduct an annual required and post licensing visit. LPA Angela Hood spoke to the Administrator, Julie Pereira, by phone and Julie stated that caregiver can sign report.

For more information on the post licensing visit please see LIC 809 dated 8/20/21.

No deficiencies cited for the post licensing visit.
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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