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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005688
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:07:03 PM

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:FAIR OAKS CARE HOMEFACILITY NUMBER:
347005688
ADMINISTRATOR:ANA, OTNIELFACILITY TYPE:
740
ADDRESS:5121 ARROYO STREETTELEPHONE:
(916) 966-6537
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Otniel Ana, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 10/8/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Otniel Ana, Administrator, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 5 bedrooms and 4 bathrooms for residents, common area, dining room, kitchen, outdoor area, and viewed PPE supplies. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. LPA obtained a copy of administrator's certificate and Administrator emailed a copy of liability insurance to LPA.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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