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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 04/12/2024
Date Signed: 04/12/2024 01:09:12 PM


Document Has Been Signed on 04/12/2024 01:09 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:WILLIAMS, MARIAFACILITY TYPE:
740
ADDRESS:8781 PHOENIX AVE.TELEPHONE:
(916) 514-9421
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martha Tufo, LicenseeTIME COMPLETED:
11:10 AM
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An office meeting was held today, 4/12/2024, via Microsoft Teams to address topics listed in this report.

The following Licensing staff were present:
Regional Manager (RM) Alycia Berryman, Licensing Program Managers (LPMs) Anthony Perez and Maribeth Senty, and Licensing Program Analyst (LPA) Michael Hood

The following representatives present:
Licensee, Martha Tufo and prospective Licensee Luigi Vo

The following topics were covered during today's meeting:
· Representatives will receive an Emergency Approval to Operate (EAO) to operate facility while a change of ownership is in process. Representatives will send the Department signed EAO by the following week
· Licensing staff reviewed stipulation and order that was issued to Licensee in 2022. Licensee will submit request to terminate stipulation and order to the Department by the following week
· Licensing staff will follow-up regarding criminal background clearance status for Representatives, as well as Administrator certificate status

LPA Michael Hood will follow-up with Representatives to ensure all the information discussed in this meeting has been implemented.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCL. The signature of the Licensee on this form acknowledges receipt of this document.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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