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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001936
Report Date: 08/13/2024
Date Signed: 08/13/2024 01:35:27 PM

Document Has Been Signed on 08/13/2024 01:35 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:TAJ RESIDENTIAL CARE IIIFACILITY NUMBER:
315001936
ADMINISTRATOR/
DIRECTOR:
IGOR KOSTHANDINOVICFACILITY TYPE:
740
ADDRESS:7088 LUDLOW DRIVETELEPHONE:
(916) 781-6199
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Gurdip Judge, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete an annual inspection. LPA met with Administrator Gurdip Judge during today's inspection. Currently there are 6 residents in care.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 1 staff room, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Water temperature measured at 120 degrees. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 3 of 6 resident files and 2 staff files. LPA reviewed medications of three residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. LPA observed a copy of current liability insurance.

During today's inspection no deficiencies were cited.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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