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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004167
Report Date: 11/24/2020
Date Signed: 11/24/2020 09:44:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FAIR OAKS VILLA HOME CAREFACILITY NUMBER:
347004167
ADMINISTRATOR:GEORGE MOGAFACILITY TYPE:
740
ADDRESS:8781 PHOENIX AVENUETELEPHONE:
(916) 966-8556
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 1DATE:
11/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Bruce Foggy, AdministratorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 11/24/2020 at 8:30 AM to conduct a health and safety check, LPA was greeted at the door by staff (S1), Sharon Dygle, who made Administrator aware of LPA's presence. At around 9AM the Administrator, Bruce Foggy arrived. LPA met with Administrator and explained the purpose of the visit.

LPA and Administrator toured the facility together, areas inspected include but are not limited to: common areas, kitchen, resident bedrooms, bathrooms, staff room, backyard, and garage. Facility was at a comfortable temperature during LPA's visit, one (1) resident, who is bedridden, and one (1) staff were present. Sufficient amount of Personal Protective Equipment and cleaning supplies were observed to be present. Medications and toxins were inaccessible to resident in care. Food supply was adequate for 2-day perishable and 7-day non-perishable. LPA observed the facility to have sufficient lighting, furniture, and was in good repair.

LPA discussed with Administrator the following:

PPE- Masks shall be worn at all times by staff while in the facility.
Cleaning and Disinfecting - The facility must clean and disinfect frequently touched surfaces regularly. LPA recommended a sanitization log that tracks when and how often cleaning and disinfecting is taking place.
Surveillance testing - 25% of staff must be tested a week.

No deficiencies were cited as a result of today's visit.

Exit interview conducted, copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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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