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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 05/03/2022
Date Signed: 05/03/2022 05:29:07 PM


Document Has Been Signed on 05/03/2022 05:29 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:
05/03/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Cleopatra Grant, Administrator TIME COMPLETED:
05:30 PM
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Licensing Program Analysts (LPA's) Sabrina Calzada and Todd Tryon arrived unannounced to conduct a case management inspection to serve an immediate exclusion to staff (S1). LPA's met with Cleopatra Grant, Administrator, and explained purpose of inspection. LPA's also met with staff (S1) , caregiver.

Prior to initiating today's inspection, LPA's 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's were screened per Covid-19 precautionary measures upon entering the facility. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical and N95 mask.

LPA's served an immediate exclusion letter to Cleopatra Grant, Administrator and S1 also.
LPA's explained the letter to both individuals and also spoke to LIcensee, Farah Chaudhary, by phone. LPA's explained 15 day appeal rights.

LPA's spoke briefly to (2) residents. LPA's observed the facility to be clean, safe and in good repair. LPA's observed Administrator contact another caregiver by phone during today's inspection.

There are no deficiencies being cited today.

Exit interview. Copy of report to be emailed to Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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