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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 02/02/2022
Date Signed: 02/02/2022 01:44:53 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) 333-3103
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bailey FitzgeraldTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 2/2/2022 at 11:15 am to conduct a required annual. LPA met with Bailey Fitzgerald, Caregiver, and explained purpose of inspection. LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Caregiver contacted Andrew Magee, Administrator, who informed LPA that he is currently unavailable until 1:00 pm. The facility has an approved mitigation plan. LPA observed (2) residents in the common area and (2) residents in their private room. LPA observed (2) caregivers to be not wearing surgical mask. Caregiver stated Administrator had informed staff face covering is not required if fully vaccinated and booster.

LPA toured the interior of the facility together with Caregiver to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathroom, kitchen and laundry room. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA advised Caregiver to post "mask required" sign at the front door for visitors. LPA informed Caregiver to have coughing etiquette signs posted throughout the facility. LPA observed toxins to be on the floor of the laundry room located in the hallway. LPA informed Caregiver all toxins must be secured at all times. LPA observed expired Administrator certificate #6053495740 (exp 09/11/2021) posted.

LPA requested a current copy of Administrator Certificate, updated LIC 308 and liability insurance by 2/7/2022.

Per California Code of Regulations, Title 22, the following deficiencies were cited from today's inspection. See LIC-809-D for deficiencies.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MANOR, THE
FACILITY NUMBER: 342700950
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the current health order and interview with Caregiver, the licensee did not comply with the section cited above that all staff are to wear maks regardless of vaccination status which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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All staff will wear face covering.
Licensee will submit a statement of compliance to CCLD.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MANOR, THE
FACILITY NUMBER: 342700950
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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Toxins will be secured and locked immediately.
Licensee will submit a statement of compliance to CCLD.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3