<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:55:18 PM


Document Has Been Signed on 02/08/2023 03:55 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:HAZEL HOME FOR SENIORSFACILITY NUMBER:
345002868
ADMINISTRATOR:GRANT, CLEOPATRAFACILITY TYPE:
740
ADDRESS:4919 HAZEL AVENUETELEPHONE:
(831) 334-1223
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 3DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Dian Evering, CaregiverTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 2/8/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Caregiver, Dian Evering, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA spoke to the Administrator, Cleopatra Grant, by phone and Administrator stated that caregiver can sign report.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 3 bathrooms for residents, common areas, kitchen, food supply, laundry room, outdoor areas, and PPE supply. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 1