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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001936
Report Date: 09/09/2021
Date Signed: 09/10/2021 08:17:34 AM

Document Has Been Signed on 09/10/2021 08:17 AM - 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:TAJ RESIDENTIAL CARE IIIFACILITY NUMBER:
315001936
ADMINISTRATOR:IGOR KOSTHANDINOVICFACILITY TYPE:
740
ADDRESS:7088 LUDLOW DRIVETELEPHONE:
(916) 781-6199
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Surinder "Geena" MannTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 09/09/2021 to conduct an unannounced annual visit using the infection control tool visit. LPA met with Facility Administrator Geena Mann and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured they washed hands just after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Caregiver.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. 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.

A couple of topics were discussed.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.

Due to computer issues, LPA had to write the report at the office on 09/10/2021, and is going to email it to Administrator for signature and request Administrator to email LPA a signed copy back.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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