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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002875
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:48:55 PM


Document Has Been Signed on 03/17/2022 03:48 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:DAISY AWARD RESIDENTIAL CARE, THEFACILITY NUMBER:
345002875
ADMINISTRATOR:MELVIN, JOYCELYN EFACILITY TYPE:
740
ADDRESS:5121 ARROYO STTELEPHONE:
(415) 444-6875
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
03/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Joycelyn Melvin, Administrator and Aurelia Ana, Administrator TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived announced for a scheduled pre-licensing inspection. LPA spoke with Joycelyn Melvin, Administrator and Aurelia Ana, Administrator. 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 facility. LPA ensured she applied hand sanitizer before entering and was wearing: KN95 Mask. LPA observed (5) residents to be watching television in the main area or in their rooms. There are not any residents currently receiving hospice services. The facility is currently undergoing a change in ownership. Currently licensed for (6) non-ambulatory residents and has a hospice waiver for (1).

LPA and Administrators toured the interior and exterior of the facility including the common areas, (5) resident bedrooms, (4) bathrooms, kitchen, outside panty and laundry area. There is a separate area with bedrooms and a bathrooms for staff. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout, including hallway night-lights. Inside temperature is 73*F. LPA observed sufficient 7+day non-perishable and 2+ day perishable supply of food. LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been last serviced 6/17/2021. LPA observed the necessary grab bars and non-skid flooring in the bathrooms and sufficient towels, linens, personal hygiene items and PPE. LPA observed a new First aid kit with all required supplies. Hot water measured 108 F. LPA observed ramps at the front and back entrance and the backyard pool to be fenced and locked.. LPA observed exit doors to have alarms on them. LPA reviewed and found (1) resident binders to be complete, organized and current. Discussed vaccination status of staff/residents and current Covid visitation protocols. LPA observe games, books and activities on site. Administrator certificate #6012874740- exp 4/8/22. Covid posters and other required postings posted.

Comp III was conducted during today's inspection. LPA to notify analyst in application unit that this pre-licensing is complete and this facility has no deficiencies.

Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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