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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700938
Report Date: 03/17/2022
Date Signed: 03/17/2022 05:19:44 PM


Document Has Been Signed on 03/17/2022 05:19 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
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: 3DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Bruce Foggy, Administrator TIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Jeffrey NIchols, caregiver, and explained purpose of inspection. Bruce Foggy, Administrator arrived around 4:20 pm and Maria Williams, House Manager, arrived at 4:30 pm. LPA observed House Manager's son to be present. Caregiver was wearing a mask. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA self- screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and was requested to do so also upon entering the facility. The following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA observed (3) residents to be watching television in the family room. There are no residents currently receiving hospice services.

LPA and Administrator toured the interior and observed the facility to ensure the health and safety of residents in care. Areas toured include: common areas,(6) private bedrooms, (4) bathrooms, staff room, kitchen and dining area, family room, and front visiting room. There is one side to the first floor designated for residents and there is another side not currently occupied. LPA observed the facility to be clean and in good repair and to pose no health and/or safety risk. LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supply for 2-3 weeks on hand. LPA observed various Covid posters in the bathrooms- to be posted at each sink. Trash cans with lids in the bathrooms. Fire extinguisher last serviced on 7/19/2021. Inside temperature of 73*. Discussed vaccination status of residents and staff as well as current visitor protocols and staffing isolation protocols per recent PIN's 22-07 and 22-09 issued in February 2022. There is a gated and locked pool in the backyard.

Discussed updating the visitor sign-in page to include date of vaccination, or negative test result.

There are no deficiencies cited during today's inspection. Exit interview with Administrator and House Manager. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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