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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:08:44 PM


Document Has Been Signed on 06/22/2022 12:08 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:MANOR, THEFACILITY NUMBER:
342700950
ADMINISTRATOR:MAGEE, ANDREWFACILITY TYPE:
740
ADDRESS:3840 DELL ROADTELEPHONE:
(916) 333-3103
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
06/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jayana CasasTIME COMPLETED:
12:10 PM
NARRATIVE
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On 06/22/2022 at 11:00 am, Licensing Program Analyst Cassie Yang arrived to the facility unannounced to conduct a case management following up on the status of the Administrator Certificate renewal. Administrator informed LPA on 2/2/2022 during annual inspection that he will send proof of renewal, but it never received.

LPA met with caregiver, Jayana Casas, who contacted Administrator, Andrew Magee, by telephone. Administrator informed caregiver that he has a meeting and was not able to meet with LPA until after the meeting. LPA informed Administrator all that is needed is proof of Administrator Certificate renewal, and if he can send his PDF version to caregiver.

LPA observed two (2) caregivers present without a face covering. LPA informed staff that mask is still required by the Department when working at the facility and asked them to put on a surgical mask. Noted, on 2/2/2022 during 1 year annual inspection, the facility was cited for not wearing mask. This will be a repeated citation within one (1) year.

LPA observed no current Administrator Certificate to be present at the facility.

LPA requested a copy of Administrator Certificate renewal to CCLD by 7/6/2022.
LPA requested a copy of an updated LIC 308 by 6/29/2022.

Exit interview was conducted and a copy of the report was left at the facility with staff.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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


Document Has Been Signed on 06/22/2022 12:08 PM - It Cannot Be Edited

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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited

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Based on observation of Caregivers not wearing mask, 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.

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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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/22/2022 12:08 PM - It Cannot Be Edited

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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2022
Section Cited

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Based on the observation, Licensing Program Analyst did not see an updated Administrator Certificate available in the facility. There are no active/pending renewal application for Administrator.

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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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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