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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:21:12 PM


Document Has Been Signed on 03/28/2022 03:21 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: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: 5DATE:
03/28/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Farah Aslam, Licensee TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection on prior license, #342700708 as annual was showing as overdue in the system. LPA met with Farah Aslam who stated that she is the new Licensee for the facility and a new license was just issued. LPA observed copy of license # 345002868, issued on 3/9/2022 under current Licensee. Facility name remains Hazel Home for Seniors.

Prior to initiating today's inspection, LPA 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. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask.

LPA and Licensee toured the facility to ensure the health and safety of residents in care. Currently, there are (5) residents and no residents are receiving hospice services. LPA observed the facility to be in clean, in good repair and to pose no health and safety risk. LPA observed paper towels, sanitizer, trash can with lid and hand-washing poster in the bathrooms. LPA observed sufficient food supply. Inside temp was 74*.
Fire extinguisher last serviced August 2021. LPA provided copy of PIN 22-07. Discussed staff and resident vaccination status and visitation protocols. LPA observed Administrator, Cleopatra Grant, on site also.

LPA and Licensee discussed the process of increasing the capacity from (6) to (12) residents. LPA stated an LIC200 needs to be completed and submitted to local fire department along with an STD850 with a request for increase.

There are no deficiencies observed during today's inspection.
Exit interview. Copy of report provided to Licensee.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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