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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:56:53 PM


Document Has Been Signed on 08/16/2022 03:56 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: 5DATE:
08/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Caregiver, Justin Seo TIME COMPLETED:
04:10 PM
NARRATIVE
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On 8/16/2022, Licensing Program Analysts (LPA's) Cassie Yang and Kevin Mknelly arrived unannounced at the facility and spoke with caregiver, Justin Seo. The purpose of this visitation was a Plan of Correction regarding the Administrator Certificate renewal, to confirm correction and if proof of renewal was submitted to CCLD.

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 was informed that temperature screening was optional. LPA's advised Caregiver to conduct screenings for all visitors. LPAs ensured the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA's observed staff to not have a mask on as facility has been cited for the same violation on 2/2/2022 and 6/22/2022.

LPAs informed Caregiver failure to make correction for the Administrator Certificate renewal by Plan of Correction due date of 8/2/2022, a civil penalty of $100 per violation per day shall be assessed.

As a result of this visit, deficiencies were observed and civil penalties were assessed. Please see the attached LIC 809-D and LIC 421FC.

An exit interview was 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: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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Document Has Been Signed on 08/16/2022 03:56 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: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

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87468.1 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...
This requirement is not met as evidenced by:
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Based on observation of Caregiver was 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: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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