<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:30:56 PM


Document Has Been Signed on 01/27/2023 02:30 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
CHICO - RESIDENTIAL, 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: 6DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 AM
MET WITH:Maria Williams and Bruce FoggyTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/27/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection. LPA met with co-Administrator, Maria Williams and explained the purpose of the visit. LPA worn the following Personal Protective Equipment: surgical mask.

LPA and co-Admin toured the interior of the facility to ensure the health and safety of residents in care. LPA observed Administrator Certificate #6003533740 to be up to date. LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable foods in the facility. LPA observed the temperature of the facility to be at 74*. LPA observed three (3) residents present in the common area and three (3) residents in their private rooms. LPA observed Room #3 to be missing a night stand. Co-Admin informed LPA that it was requested by the family for facility to remove the night stand and lamp.

During today's inspection, LPA is requesting a copy of LIC 500, LIC 308, current liability insurance and Administrator Certificates of Bruce Foggy and Maria Williams to be emailed to LPA Yang by Friday February 3, 2023.

LPA and co-Administrator completed the infection control domain together and the facility is in substantial compliance. As a result of today's visit, no deficiencies were observed.

Exit interview conducted with Administrator Bruce Foggy, and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1