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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 02/26/2021
Date Signed: 02/26/2021 02:32:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MANOR, THEFACILITY NUMBER:
342700950
ADMINISTRATOR:MAGEE, ANDREWFACILITY TYPE:
740
ADDRESS:3840 DELL ROADTELEPHONE:
(916) 832-7959
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
02/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Andrew MageeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melana Llopis contacted the facility via Video-chat on 02/26/2021 for a scheduled Prelicensing tele-visit due to Covid-19 and precautionary measures. LPA spoke with the Administrator, Andrew Magee and reviewed the purpose of the visit. Facility has a fire clearance for four (4) non-ambulatory residents and two (2) ambulatory residents. The facility also has a hospice waiver for two (2). The facility currently has six (6) residents in care, of which four (4) are non-ambulatory and two (2) are on hospice care. Hospice care plans were readily available for review.

LPA and Administrator virtually toured the facility together, areas inspected include but are not limited to the following: facility entryway, kitchen, laundry room, resident bedrooms and facility restrooms, hallway, and backyard. LPA observed required signage posted in the facility. The facility has a visit screening in place. Masks are required to be worn in the facility by staff at all times. The facility has required furniture in resident rooms and sufficient lighting. Water was measured at 112 degress F. The fire extinguisher was found to be fully charged and last serviced on 11/13/2020. Sharps and toxins were observed to be locked and inaccessible to residents in care. Medications were also observed to be locked and inaccessible to residents. LPA observed the facility to have an adequate supply of 2 day perishable food items and an adequate supply of 7 day nonperishable items. LPA observed a sufficient amount of Personal Protective Equipment. The smoke detectors were found to be present throughout the facility and in working order. The carbon monoxide was observed to be in working order as well. First aid kit was found to be complete.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.
Component III was waived as licensee has recently completed one and has other facilities in substantial compliance. LPA will contact the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

Exit interview conducted and copy of report was emailed to licensee, signed copy to be returned to Community Care Licensing, a signed copy should be retained for facility records.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
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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