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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 02/09/2022
Date Signed: 04/29/2022 02:58:12 PM


Document Has Been Signed on 04/29/2022 02:58 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: 3DATE:
02/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cleopatra GrantTIME COMPLETED:
03:20 PM
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On 2/9/2022 at 1:40 pm, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Pre-licensing inspection for change of ownership referencing the infection control domain. LPA met with Caregiver, Leah Cummingham, and explained the purpose of the visit. Prior to initiating the inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Administrator arrived to the facility shortly afterwards.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, staff office, and backyard. In the areas toured, no immediate health, safety, or personal rights violations were observed.

LPA and Administrator completed the infection control recommendations and facility was found to be in substantial compliance at this time. LPA confirmed that masks were worn by staff. LPA observed a more robust lock on the knife drawer and kitchen sink cabinet, all toxins and chemicals be secured from residents. LPA observed medication to be stored in a secured office.

LPA completed the Component III Orientation with Administrator.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
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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