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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002560
Report Date: 05/18/2021
Date Signed: 05/18/2021 03:35:55 PM

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: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:
05/18/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Nordia Gouldbourne, Lead care giver TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a health and safety check for resident (R1) who recently moved to the facility. LPA met with Nordia Gouldbourne, Lead care giver, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by Nordia, prior to entering the facility.

At the start of the inspection, LPA was informed and observed that resident was sleeping in resident's private room. Care staff indicated that resident moved to the facility on 5/10/2021 and is currently receiving hospice services. Additionally, care staff indicated that resident has been drinking Ensure and water to take medications with and is receiving sponge baths and is not smoking. LPA reviewed the hospice file for resident. Administrator, Ophelia, arrived at approximately 3:00 pm with groceries. LPA spoke to her about how resident is doing. Administrator reiterated that resident is drinking Ensure and water and has a light appetite and has been in pain more lately. LPA was informed that hospice nurses are visiting twice weekly and monitoring resident and are made aware of any changes in condition for resident.

LPA attempted to speak briefly with resident, identifying herself, but resident was waking up from a nap and did not wish to speak to LPA and requested some water and pudding from Administrator. LPA concluded the inspection.

There are no deficiencies being cited on this report.

Exit interview. Copy of report left with Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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