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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095920191
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:19:43 PM

Document Has Been Signed on 01/15/2025 12:19 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PLACERVILLE SENIOR LIVINGFACILITY NUMBER:
095920191
ADMINISTRATOR/
DIRECTOR:		KABAI, ECATERINAFACILITY TYPE:
740
ADDRESS:2637 LIBERTY MINE CT.TELEPHONE:
(916) 616-7020
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 4CENSUS: 0DATE:
01/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator Ecaterina KabaiTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived to conduct an announced Pre-Licensing visit and met with applicant Ecaterina Kabai. Applicant holds a current administrator certificate (#7035503740 with expiration date 06/26/2025).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. Facility inspection is done for these areas but not limited to one (1) bedroom, one and a half (1.2) bathrooms, storage area, outside area and laundry area . Bathrooms and bedroom were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use. Facility was approved for 2 non-ambulatory residents. Water temperature read at 115*.

Component III for RCFE was completed with Applicant during today's visit. LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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