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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002855
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:00:33 PM

Document Has Been Signed on 12/10/2021 12:00 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:DOLCE VITA HOME CAREFACILITY NUMBER:
315002855
ADMINISTRATOR:POLYAKOVA, ALENAFACILITY TYPE:
740
ADDRESS:141 HINCKLEY CTTELEPHONE:
(916) 521-5393
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natalya Andreyea, Applicant; Shanice Frazer, Assistantive Administrator; Alena Polyakova, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA) K. Hiratsuka and L. Muscan, arrived at the facility announced on 12/10/2021 to conduct an announced prelicensing visit. LPA met with Natalya Andreyea, Applicant; Shanice Frazer, Administrator Assistant; Alena Polyakova, Administratorr, and explained the purpose of the visit. Prior to initiating the visit, LPAs 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 wash hands shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator.
This facility has a fire clearance for six non-ambulatory residents. The main entrance opens to a common area. To the immediate right of the main entrance to there is a hallway leading to two private resident rooms that share a full bathroom. The full bathroom is accessible by the two resident rooms. There is a second hallway on the right that leads to a caregiver room and a large private resident room that has an exit to the outside and full private bathroom. In front of the main entrance there are two private rooms. To the left of the main entrance is a full common bathroom and one private resident room. To the left of the main entrance there is a doorway that leads to the main common area that has the kitchen, dining, and sitting areas. Behind the kitchen is the locked laundry room and doorway leading to the garage. There is an exit to the outside. There is a locked storage shed to the right of the facility in the backyard and and gate on the same side as the garage. There is a gate in front of the main entrance that is to be left unlocked at all times. There are locked cabinets for medications in the kitchen area.

Component III orientation was conducted..

LPA did not find any deficiencies during this visit. LPA is going to submit this application to the application's specialist for their final review.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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