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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 10:29:45 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:OfficeUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Administrator, Bruce FoggyTIME COMPLETED:
10:45 AM
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An office meeting was held today on 11/24/2020 via teleconference line due to COVID-19 and pre-cautionary measures. The purpose of today's meeting was to address the Change of Ownership procedures and clarify any questions the current Licensee and upcoming Licensee have regarding the required process.

The following Licensing staff were present:
Angela Hood and Laura Munoz

The following representatives /present:
Property buyer/Administrator, Bruce Foggy

The following topics were covered during today's meeting:
  • Required 60-day notices to residents, responsible parties, and Ombudsman
  • Lease back agreement
  • Licensee is still accountable for the facility until the licensure has been approved by Community Care Licensing (CCL)
  • Administrator's certificate
  • Staffing schedule

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to CCL.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
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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