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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 07/19/2022
Date Signed: 07/21/2022 08:56:50 AM


Document Has Been Signed on 07/21/2022 08:56 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:
07/19/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Andrew Magee, Administrator and LLC member TIME COMPLETED:
03:00 PM
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An office meeting was conducted at 2:00 pm on 7/19/2022 at the Sacramento North Regional Office virtually via Teams Meeting. Present in the meeting were Administrator, Andrew Magee, Licensing Program Manager (LPM), Maribeth Senty, Licensing Program Analysts (LPA), Cassie Yang and LPA Sabrina Calzada.
Licensee was advised that the purpose of today's office meeting is to address current compliance issues at this facility and at each of the (2) related facilities and that further citations may be issued. The Administrative Action process was explained to the licensee that further citations may result in an elevation to a formal Non-Compliance Conference, which could then lead to a referral to the Department’s Legal Division of possible revocation of license.

TOPICS OF DISCUSSION:

· Administrator Recertification- Administrator Certificate #6053495740 (exp 9/11/2021)- Administrator agreed to submit all documents and full payment needed for renewal to CCLD by COB 8/2/2022.
· LIC308, LIC500 and proof of liability insurance for all facilities.- Administrator agreed to provide requested documents by COB 8/2/2022. LPM noted these documents are available online. Discussed Administrator sending a screen shot of current electronic staffing schedule, if preferred over a hard copy. Proof of current liability insurance for the facility was provided to the Department on 7/20/2022.
  • The Department will not issue a civil penalty for failure to correct for the mask citation.
  • smoke/alarms- Administrator to submit Incident Report by COB on 7/20/2022 detailing contact with local fire dept and what follow up action is needed to ensure compliance.
· Administrator to submit screen shot of updated visitor log by COB 7/20/2022.
· Discussed required reporting requirements and examples of incidents requiring reporting.
· Administrator to submit updated LIC309 with correct information reflecting any changes to LLC, as
reported to CA Secretary of State by COB 8/2/2022.
· Infection Control Plan (due 6/30/2022) to be resent to assigned LPA for each facility.
· Possible referral to Technical Support Program- Administrator indicated an interest.
· Administrator to advise Department of any facility closures or change in ownership

There are no deficiencies issued during today's meeting.

Exit interview. Administrator was informed that a copy of today's report would be emailed to him for a signature on a hard copy and then returned to CCLD via email by 7/20/2022.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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