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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:12:07 PM


Document Has Been Signed on 05/12/2022 05:12 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:
05/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Dian EveringTIME COMPLETED:
05:15 PM
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On 5/12/22, Licensing Program Analyst (LPA) arrived to conduct a POC visit of citations issued 5/2/22.
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 mask. LPA was screened by caregiver at the facility.

LPA found that three plans of correction due for Dementia Training 87705(c)(3), Medication Training 1569.69(a) and New staff training have not clearly been met. LPA discussed the issue with Licensee and Administrator. LPA will return to review training documentation. If not met, failure to correct civil penalties may be applied.

LPA confirmed that Excluded staff are not present. LPA re-associated staff who had been disassociated.
LPA advised a room change for resident in -ambulatory only room who has become non-ambulatory to move to room with 2 exits.

No citations are issued at this time.

Report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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