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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:05:47 PM


Document Has Been Signed on 07/28/2022 05:05 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:
07/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Diane Evering, caregiver TIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to obtain a signature on page 3 of complaint # 25-AS-20220412134911 for findings delivered on 7/21/2022 and also to change findings for complaint #25-AS-20220411160405 from "Unsubstantiated" to "Unfounded".

. LPA met with Diane Evering, caregiver LPA spoke to Licensee, Farah Chaudhary, by phone and explained reason for inspection. 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 community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA observed (2) residents to be eating dinner in the common area and staff Diane to be assisting one of the residents.

LPA obtained the necessary signatures for the amended page and amended complaint findings.

There are no deficiencies issued during today's inspection.

LPA provided the facility with some PPE supplies from the Department- gloves, wipes, gowns and sanitizer.

Exit interview. Copy of report provided to facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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