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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 05/14/2021
Date Signed: 05/14/2021 10:33:53 AM

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: 4DATE:
05/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Staff- Giovanni Tufo TIME COMPLETED:
10:40 AM
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On 5/14/2021 at 10:10 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted Administrator, Maria Williams, to conduct an unannounced Case Management Tele-visit. LPA explained the purpose of the telephone call. Administrator is currently present at a different facility caring for residents. Administrator gave staff permission to Facetime with LPA to conduct Case Management Tele-visit.

An office visit was conducted which outlines the expectations of the facility. Administrator agrees to send Community Care Licensing (CCL) weekly schedule updates to ensure CCL have the most current staffing schedule.

LPA reviewed current LIC 500 provided by the facility. LPA observed staff listed on the LIC 500 present at the facility working.

LPA requested for updated care plans for all residents in care.

No deficiencies cited.

An exit interview was conducted with staff, Giovanni Tufo, and a copy of this report will be provided to the facility via email. This report is to be signed and returned to LPA via email.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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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