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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:38:29 PM


Document Has Been Signed on 04/25/2022 03:38 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: 4DATE:
04/25/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Farah Chaudhary, Licensee, Harjot Singh, Business Partner, AZ Chaudhary, and Cleo Grant, Administrator TIME COMPLETED:
01:00 PM
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A tele-visit meeting was held on 4/25/2022. Present in the meeting were Farah Chaudhary, Licensee, Harjot Singh, Business Partner, Cleopatra Grant, Administrator and AZ Chaudhary, Licensee's spouse and owner of propety of Hazel Home for Seniors, Regional Manager, Alycia Berryman, Licensing Program Manager, Maribeth Senty, and Licensing Program Analyst, Sabrina Calzada. The office meeting process was explained during the meeting:

Today's meeting was to address the following issues:
  • Eviction notice issued 4/8/22- email sent to Licensee on 4/8/22 that notice was approved
  • Audio and video surveillance being used in the common areas-
  • Reporting requirements
  • Provide technical assistance


The Facility agrees to do the following:
  • Immediately cease using video and audio surveillance at the facility due to personal rights violation
  • Submit a waiver to the Department requesting approval of video surveillance only
  • Update Plan of Operations in the facility Admission Agreement explaining use of video surveillance and submit to the Department for approval
  • Review Regulation 87209- Program Flexibility; 87405- Administrator Qualifications; 87507- Admission Agreement- in Evaluator Manual at DSS website.
  • Licensee was advised of the responsibility to ensure staff is fully trained and provide training opportunities
  • Training links available- can access from Evaluator Manual
  • Update resident paperwork to reflect new license name
  • Discussed working relationship with DSS- LPA is the first line of contact.


Items discussed were summarized at the conclusion of the virtual meeting and Licensee was informed a copy of this report would be emailed to her following the meeting for signature.

There are no deficiencies cited during this report.




SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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