<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002560
Report Date: 06/25/2026
Date Signed: 06/25/2026 03:13:12 PM

Document Has Been Signed on 06/25/2026 03:13 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:PHOENIX MANORFACILITY NUMBER:
347002560
ADMINISTRATOR/
DIRECTOR:		BIRLADEANU, OPHELIAFACILITY TYPE:
740
ADDRESS:8682 PHOENIX AVENUETELEPHONE:
(916) 863-7470
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
06/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ophelia Birladeanu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on June 25, 2026 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 111 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on site. LPA observed the backyard and perimeter of the care home and observed emergency exits to be unobstructed. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked two (2) residents' medications and found medication to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA request a copy. LPA also requested copies of an updated staff roster and emergency disaster plan during visit.

** Report continued on 809-C **
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PHOENIX MANOR
FACILITY NUMBER: 347002560
VISIT DATE: 06/25/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During inspection, LPA reviewed residents' admission agreements to include the following statement: “Once the level of care changes for a resident, and needs hospice care, the daily rate is $250. The full month amount is required once the resident is signed into hospice care. If the resident expires before the end of the month, there is NO REFUND.”

Per Health and Safety Code §1569.652(c), “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.” Per Title 22, Division 6, Chapter 8, Section 87507(h)(4), “The admission agreement shall not contain the following: Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.”

As a result of this visit, deficiencies were cited pursuant to California Code of Regulations Title 22, Division 6, Chapter 8 and the Health and Safety Code. Deficiencies are listed on 809-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/25/2026 03:13 PM - It Cannot Be Edited


Created By: Michael Hood On 06/25/2026 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PHOENIX MANOR
FACILITY NUMBER: 347002560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. (...)

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and records reviewed, the facility did not ensure to have a certified administrator on duty, which poses a potential health, safety, and personal rights violation to the residents in care.
POC Due Date: 08/25/2026
Plan of Correction
1
2
3
4
Facility will ensure that assigned administrator obtains an updated administrator certificate. Facility will submit proof of administrator certification to LPA by POC due date of August 25, 2026.
Type B
Section Cited
CCR
87507(h)(4)
87507 Admission Agreements (h) The admission agreement shall not contain the following: (4) Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed, the facility did not ensure that admission agreements for residents did not violate rights specified in Health and Safety Code section 1569 et seq. due to refund policies indicated for hospice residents, which poses a potential health, safety, and personal rights risk to the residents in care.
POC Due Date: 08/25/2026
Plan of Correction
1
2
3
4
Facility will update all residents' admission agreements to remove any stipulations that violate rights specified in Section 87468 and in Health and Safety Code section 1569 et seq. Facility will provide copies of updated admission agreements to LPA by POC due date of August 25, 2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4