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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:04:37 PM


Document Has Been Signed on 05/13/2022 01:04 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: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: 3DATE:
05/13/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria Williams, Administrator/House ManagerTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to ensure facility is in compliance with Health and Safety Code ยง1569.38 Posting of licensing reports; disclosure to new residents following the department serving an Accusation on 4/27/2022. LPA met with Maria Williams, House Manager, who advised Administrator, Bruce Foggy, of purpose of inspection. LPA observed (3) residents to be watching television in the tv room near the kitchen.

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 and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask.

LPA confirmed there are no positive cases of staff/residents with symptoms, upon entering the community.
House Manager and LPA discussed the posted notice, dated 4/29/2022, displayed on the wall in the front room near other Department postings. LPA observed the notice to contain the required elements. House Manager indicated the Ombudsman was notified as well as all residents/representatives. LPA attempted to speak to (1) resident but resident was unable to confirm information needed.

There are no deficiencies being cited today. Exit interview with House Manager. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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