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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:29:58 PM


Document Has Been Signed on 01/27/2023 02:29 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: DATE:
01/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maria Williams and Bruce FoggyTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit pursuant to a Stipulation and Waiver and Order adopted on 08/10/2022. LPA met with co-Administrator Maria Williams, and explained the purpose of the visit.

During today's inspection, LPA observed a copy of the Stipulation posted a conspicuous place by the common area. LPA and co-Admin discussed the requirements the Department is expected from the facility. LPA and co-Admin further discussed the facility creating a Compliance binder to make quarterly visits more organized.

LPA confirmed all staff are cleared and associated with the facility via Guardian website. LPA confirmed all staff listed in the LIC 500 to be first aid certified. Co-Admin informed LPA all staff are aware and in agreeance in any imminent threat, staff are to contact 911. Co-Admin confirmed LIC 624 will be sent to CCLD for all incidents such as AWOLs, falls, death, serious injuries, etc.

As a result of today's visit, no deficiencies observed

Exit interview conducted with Administrator, Bruce Foggy. Copy of 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)
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