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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 09/28/2022
Date Signed: 09/28/2022 05:30:32 PM


Document Has Been Signed on 09/28/2022 05:30 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:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:3CENSUS: 0DATE:
09/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Craig FowlerTIME COMPLETED:
01:27 PM
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On 09/28/2022, Licensing Program Analyst (LPA) Jacob Williams conducted a Prelicensing inspection. LPA met with Administrator, Craig Fowler, and explained the purpose of the visit. LPA wore a surgical mask while at the facility.

LPA toured the facility together with Administrator. The facility has three (3) resident bedrooms and two (2) bathrooms. LPA observed the common areas, kitchen area, bedrooms, and bathrooms. LPA observed knives/ sharps area were locked in the cabinet underneath the sink. Toxic and cleaning supplies are locked away. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. LPA observed required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. The hot water temperature was measured in the kitchen at 115 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer. LPA observed centrally stored medications area were locked and inaccessible.
LPA observed one (1) fire extinguisher, smoke detectors, and carbon monoxide detectors in the facility. Licensing complaint poster is being ordered and will be hung in prominent location.

Component III presentation conducted with administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with administrator and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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