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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004963
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:24:00 PM


Document Has Been Signed on 04/22/2022 03:24 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:MILES MANORFACILITY NUMBER:
347004963
ADMINISTRATOR:MILES, RACHELFACILITY TYPE:
740
ADDRESS:4301 WATKINS DRIVETELEPHONE:
(916) 967-9049
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:15CENSUS: 15DATE:
04/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Kimberly Rosa, Administrator TIME COMPLETED:
02:48 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met Administrator, Kimberly Rosa., and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. Facility currently has (15) residents and (6) residents are on hospice.

Administrator contacted Licensee by phone and discussed reason for inspection. LPA provided amount of overdue annual fees. Administrator stated that Licensee believed they were paid already and wasn't aware. LPA assisted Administrator make payment on line and observed confirmation number.

LPA also toured the facility with the Administrator during today's inspection. LPA observed (8) residents to be in the front common room, watching television, doing a puzzle or napping. LPA observed (7) residents to be resting in their rooms. LPA observed the facility to be clean and in good repair and to not pose a health or safety risk to residents in care.

LPA and Administrator discussed vaccination status of residents and staff and second booster eligibility. Also discussed visitation protocols in place and PIN 22-07. Facility is encouraging visitors visit outside visitation or
use a separate room near the entrance if resident has a shared room.


There are no deficiencies issued today.

Exit interview. Copy of report provided.



SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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