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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002560
Report Date: 06/08/2022
Date Signed: 06/08/2022 12:30:39 PM


Document Has Been Signed on 06/08/2022 12:30 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: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:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ophelia Birlandeanu, Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver, Hazel Minott, and Ophelia Birlandeanu, Administrator and explained purpose of inspection. LPA observed caregiver, Rafael Minott, to be present also. All staff were wearing masks. LPA observed (3) residents in the common area, (2) residents to be in their rooms and (1) resident outside on the back patio. There are currently (0) residents on hospice services. The facility is licensed for (6) non-ambulatory residents. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA and Administrator toured the interior and exterior of the facility, including (6) private resident bedrooms, (3) bathrooms, kitchen, common areas, locked laundry area, and staff room. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 77* F. Fire extinguisher last serviced 6/10/2021- to be re-serviced by 6/10/2022. LPA observed secured toxins, medications and sharps and sufficient 2+day perishable/7+day non-perishable food. First aid kit on site. Exit doors have alarms on them. LPA observed soap, sanitizer, and trash cans with lids in the bathrooms. Administrator to post 12-step hand-washing posters in the bathrooms/kitchen. LPA observed sufficient PPE supply and incontinent products, activities, and books.
LPA observed various Covid posters throughout as well as other required postings. LPA to email additional Covid posters to print/display. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols per PIN 22-07. Administrator to add contact information to visitor sign-in log. All staff are cleared/associated.

LPA requested an updated copy of LIC500, LIC308 and a copy of the current liability insurance by 6/15/22. Exit interview. There were no deficiencies observed during today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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