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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002933
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:50:31 AM


Document Has Been Signed on 10/13/2022 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GREY MANORFACILITY NUMBER:
345002933
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5216 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
10/13/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Karl Ramos, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Michael Hood met with applicant, Karl Ramos, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as NORTH AVENUE VILLA Facility #: 347003843. The facility has a fire clearance for six (6) bedridden residents. Applicant holds a current administrator certificate (#6063204740 with expiration date 7/26/2024).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115 degrees F. LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply at the facility. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. LPA reviewed two (2) resident files and two (2) staff files.

LPA observed during visit that one (1) fire extinguisher needs to be serviced, and files for residents were missing items. LPA indicated all the above observations need to be fixed and facility will send corrections to CCLD within 7 days from today's date.

Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval once requested items have been received. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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