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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 03/10/2021
Date Signed: 03/10/2021 02:46:48 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 VILLAFACILITY NUMBER:
342700938
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:8781 PHOENIX AVE.TELEPHONE:
(916) 514-9421
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
03/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bruce Foggy, Administrator and Maria Williams, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Angela Hood contacted the Administrators, Bruce Foggy and Maria Williams, to conduct a virtual pre-licensing inspection of the facility. The visit was conducted virtually due to COVID-19 and precautionary measures. Applicant holds current administrator certificate #6003533740 exp. 8/26/2021. There are currently 4 residents residing in the care home.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six bedrooms and six bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 119 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents.

LPA observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. The care home has hardwired smoke detectors and two carbon monoxide detectors that are operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA reviewed a resident file and a staff file to be complete in documentation.

Pre-licensing passed and Component III was previously completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of this report shall be submitted to CCLD. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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