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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700708
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:18:52 PM


Document Has Been Signed on 03/28/2022 03:18 PM - 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: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: 0DATE:
03/28/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Farah Aslam, LicenseeTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask.

LPA met with Farah Aslam who stated that she is the new Licensee for the facility and a new license was just issued. LPA observed copy of license # 345002868 that was issued on 3/9/2022 to Licensee, Sacramento Hospitality, Inc. Facility name remains Hazel Home for Seniors.

A required annual inspection was due to be conducted by 1/7/2022 under license #342700708.

This report is being created to clear the annual in the system before closing the license due to a change in ownership.

There are no deficiencies cited under this report.

Exit interview with Farah Aslam, Licensee. LPA was provided with copy(2) of prior license since it will be closed in the system.

Copy of today's report provided to current Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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