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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 06/27/2022
Date Signed: 06/27/2022 11:53:34 AM


Document Has Been Signed on 06/27/2022 11:53 AM - 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: 5DATE:
06/27/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jayana CasasTIME COMPLETED:
10:15 AM
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On 6/27/2022, Licensing Program Analyst (LPA) Cassie Yang and Kevin Mknelly arrived unannounced at the facility and spoke with Caregiver, Jayana Casas. The purpose of this visitation was a Plan of Correction regarding the mask, to confirm correction and if a form was submitted to CCLD. LPA Yang contacted Administrator, Andrew Magee, who informed LPA's he will arrive to the facility in 45 minutes. LPA Mknelly asked which senior caregiver can CCLD conduct the visit with, and Administrator confirmed it was Jayana Casas. Prior to initiating today's visitation, LPAs 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. LPAs were not screened by Caregiver prior to entering the community. LPAs advised Caregiver to conduct screenings for all visitors. LPAs ensured the following Personal Protective Equipment (PPE) was worn: surgical mask.

When asked for the current LIC 308, Caregiver, Jayana Casas, informed LPA's that Administrator keeps files off site. LPA's requested for administration files to be accessible to LPAs during all visitations. Administrator informed Caregiver that Plan of Correction was submitted over the weekend. LPA will follow up with CCLD for confirmation.

LPA's observed two (2) smoke detectors to be removed. Administrator informed LPA Mknelly that he has a handyman coming in today to resolve this matter. LPAs requested Administrator to submit proof of resolution to LPA Yang via email or fax.

As a result of this visit, a LIC 9102 technical violation and a civil penalty was issued for repeated violation within the period of 12 months. Exit interview conducted and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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