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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 10/11/2021
Date Signed: 10/11/2021 03:58:40 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:MANOR, THEFACILITY NUMBER:
342700950
ADMINISTRATOR:MAGEE, ANDREWFACILITY TYPE:
740
ADDRESS:3840 DELL ROADTELEPHONE:
(916) 832-7959
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Andrew Magee, Administrator TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a health and safety check and reason for inspection to caregivers upon arrival to facility. LPA met with Andrew Magee, Administrator, upon arrival to the facility. LPA observed caregivers, Gage, Kristin and Jayana, to also be present, wearing masks during today's inspection. Administrator confirmed there are (6) residents present and there is currently (1) resident receiving hospice services. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA and Administrator toured the interior of the facility and observed (3) residents to be in the front room and (3) residents to be asleep in their individual rooms. LPA asked (2) residents how they are doing and residents indicated they are doing fine and well cared for.

LPA observed the facility to be clean and in good repair and Administrator stated (1) bathroom will be remodeled soon. LPA observed (1) vacant resident room and communal shower room. .LPA observed sufficient 2+ day perishable food, with fresh produce, and 7+ day non-perishable food on site. LPA observed the fire extinguisher to have been last serviced 11/11/2020. Administrator certification pending renewal- expired 9/11/2021- #6053495740. LPA observed a pool to be enclosed by a fence and locked gate with a padlock.

From areas observed during today's inspection, LPA did not observe any deficiencies.

Exit interview. Copy of report to be emailed to Administrator, as requested.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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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