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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:44:16 PM

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: 6DATE:
05/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff- Ernest TIME COMPLETED:
01:50 PM
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On 5/20/2021 at 1:30 PM, Licensing Program Analyst (LPA) Sarena Keosavang conducted an unannounced virtual Case Management visit. LPA met with facility staff and explained the purpose of the call.

LPA was granted entry into the facility via Google Duo. LPA toured the interior and exterior of the facility with staff to ensure there are no health and safety concerns. LPA observed six residents present at the facility.

LPA interviewed staff in regards to work schedule.

LPA reviewed current LIC 500 provided by the facility. Staff was not listed on the LIC 500. LPA requested for Administrator to update LIC 500 and submit to LPA via email.

No deficiencies cited.

An exit interview was conducted with staff 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: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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