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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002560
Report Date: 09/09/2020
Date Signed: 09/09/2020 03:29:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PHOENIX MANORFACILITY NUMBER:
347002560
ADMINISTRATOR:BIRLADEANU, OPHELIAFACILITY TYPE:
740
ADDRESS:8682 PHOENIX AVENUETELEPHONE:
(916) 863-7470
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
09/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ophelia Birladeanu, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Angela Hood spoke with the Administrator, Ophelia Birladeanu, via telephone to conduct a case management visit. Today's visit was conducted by telephone due to COVID-19 and precautionary measures. The purpose of the visit is to follow-up on a death report that was received by the Department.

On 7/2/20, resident (R1) was sent to the hospital after a fall in their bedroom, which resulted in R1 hitting their head on the railing of their bed. The facility was notified that R1 had passed away that evening at the hospital. LPA interviewed Ophelia as well as requested documentation to be emailed to LPA. Ophelia agreed to send LPA the death certificate once received.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of the report shall be submitted to CCLD within 10 days of receipt of this report. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
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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