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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001936
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:27:28 PM

Document Has Been Signed on 09/07/2023 01:27 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: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: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Glenn Sahetapy and Racquel BereciarteTIME COMPLETED:
01:35 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Caregiver Glenn Sahetapy. Caregiver Racquel Bereciarte, was also present. Administrator Gurdip Judge, arrived during visit but had to leave after a short time. This facility has four private resident rooms and one shared room. There is a caregiver room that leads to the garage. The main entrance opens to a small foyer. There is a hallway on the right that leads to shared resident room that has an exit to the outside as well as a full bathroom and a common half bathroom. To the left of the main entrance is a hallway that leads to the rest of the resident rooms as well as the kitchen. There is a large room across the main entrance that is a sitting and dining area as well as a doorway on the left that leads to the main sitting area and kitchen. There is also a dining table in the kitchen area. There is a sliding glass door that is blocked by a couch in the sitting area across the main entrance because that sliding door is not considered an exit to the outside. There is a gate on the same side as the garage. The front yard has a small fenced in area that has two gates leading to the front door. Both gates are unlocked. There is a locked cabinet in the kitchen for medications and sharp knives.

-two resident records were reviewed
-three staff files were reviewed
-two resident medication records were reviewed

The following shall be updated and submitted to Community Care Licensing by 09/25/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility


no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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