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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920139
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:10:47 PM


Document Has Been Signed on 08/14/2024 03:10 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:FAIR OAKS VILLA, LLCFACILITY NUMBER:
345920139
ADMINISTRATOR:WILLIAMS, MARIAFACILITY TYPE:
740
ADDRESS:8781 PHOENIX AVE.TELEPHONE:
(916) 844-7095
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Maria Williams, AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Michael Hood met with Administrator, Maria Williams, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as FAIR OAKS VILLA Facility #: 342700938. The facility has a fire clearance for six (6) non-ambulatory residents. Administrator has an active certificate (#7000852740 with expiration date 8/26/2025).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and five (5) 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 119.7 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. 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 to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA reviewed four (4) resident files and two (2) staff files.

Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. 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: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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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