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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002560
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:59:32 PM


Document Has Been Signed on 06/20/2023 02:59 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:BIRLADEANU, OPHELIAFACILITY TYPE:
740
ADDRESS:8682 PHOENIX AVENUETELEPHONE:
(916) 863-7470
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Ophelia Birladeanu, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 6/20/23 to conduct a Required-1 Year Inspection utilizing the inspection tool. Licensee gave permission to have caregiver, Hazel Adassa H. Minott, sign additional pages to the report.

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. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 116 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 cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed five resident files and three staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87203 regarding fire extinguishers not being serviced and carbon monoxide detectors not being installed. Deficiency is listed on 809-D. An immediate civil penalty per Health and Safety Code ยง 1548 in the amount of $500 for the date of 6/20/2023 is assessed for a violation that the department determines was a fire clearance violation.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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Document Has Been Signed on 06/20/2023 02:59 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not ensure that fire extinguishers were serviced and carbon monoxide detectors were installed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee will service fire extinguishers and install carbon monoxide detectors. Licensee will submit proof to LPA be POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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