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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 04/22/2021
Date Signed: 04/22/2021 01:16:31 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: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: DATE:
04/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bruce Fogg, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today to conduct an external health and safety check case management visit and met with the Administrator, Bruce Foggy. The purpose of today's visit was to follow-up on information obtained by CCLD regarding staffing at the care home. There are currently 4 residents residing at the care home.

During today's visit, LPA interviewed the Administrator and staff (S1), as well as obtained a copy of the facilities LIC 500 Personnel Report.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of the report shall be submitted to CCLD.

Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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