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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003908
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:14:54 PM


Document Has Been Signed on 09/15/2022 04:14 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:FAIR OAKS CARE HOME AT MONTE PARKFACILITY NUMBER:
347003908
ADMINISTRATOR:TOMASIC, ZELKAFACILITY TYPE:
740
ADDRESS:8156 MONTE PARK AVENUETELEPHONE:
(916) 267-3867
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:5CENSUS: 1DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Zelka Tomasic, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 9/15/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Zelka Tomasic, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

LPA toured the facility to ensure the health and safety of the resident in care. Areas toured include but are not limited to: 4 bedrooms and 2 bathrooms for residents, common area, dining room, kitchen, outdoor area, and PPE supplies. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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