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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001936
Report Date: 09/19/2022
Date Signed: 09/19/2022 03:14:10 PM

Document Has Been Signed on 09/19/2022 03:14 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
CHICO - RESIDENTIAL, 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:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Gina Judge TIME COMPLETED:
03:35 PM
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On 9/19/2022 at 2:30 PM, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required- 1 Year annual. LPA met with Staff/Assistant Administrator, Gina Judge, and explained the purpose of the visit. Prior to today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility currently has (6) residents and (1) resident on hospice services.

LPA and Staff toured the interior and exterior of the facility including bathroom, (5) resident bedrooms, laundry room, kitchen, backyard and common area. LPA observed (2) residents to be in the common area, (1) resident in the dining area, and (3) residents to be in their private rooms. In the areas toured, no immediate health and safety risk were observed. LPA observed the facility to have thorough documentation of visitation screening. LPA observed the facility to have the Ombudsman and CCLD posters to be posted in the hallway. LPA observed paper towels, soap and hand washing signs in bathroom. LPA observed the facility to have COVID-19 signs to be posted throughout the facility. LPA observed sharps, toxics and medication to be locked and secured. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishables. Fire extinguishers last serviced 4/8/2022. Staff and LPA discussed the PIN regarding Monkeypox Addendum. LPA and Staff completed the infection control domain together, and at this time the facility was found to be at substantial compliance.

LPA requested a copy of current liability insurance, Administrator Certificate, LIC 308, and LIC 500 during today's inspection by 9/30/2022. As a result of today's inspection, no deficiency was observed.

Exit interview was conducted. A copy of report was left at facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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