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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:40:29 PM


Document Has Been Signed on 01/30/2024 03:40 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
01/30/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Maria Williams, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/30/2024 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 8/10/2022-8/10/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Maria Williams.

During today's visit, LPA reviewed the following stipulations of the order:

1. Staff shall be sufficient in number
-During inspection, LPA observed LIC 500 and staff schedule and found staff to be sufficient in number

2. Staff shall have CPR and First Aid
-LPA observed active CPR and First Aid cards for staff on site

3. Facility shall report unusual incidents
- LPA observed completed unusual incident reports sent to the Department

4. Facility shall allow visitation
-LPA observed visitor log on site

5. Staff shall have criminal background clearance
- LPA checked criminal background clearance for all staff

LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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