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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920089
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:45:34 PM

Document Has Been Signed on 12/11/2024 02:45 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:FANDANGO HOME CAREFACILITY NUMBER:
315920089
ADMINISTRATOR/
DIRECTOR:		TATISHVILI, MARINAFACILITY TYPE:
740
ADDRESS:5496 FANDANGO LOOPTELEPHONE:
(916) 222-0736
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Marina TatishviliTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson arrived at the care home today and met with the Administrator, Marina Tatishivili, to conduct an annual required and post licensing visit.

For more information on the post licensing visit please see LIC 809 dated 12/11/2024.

No deficiencies cited for the post licensing visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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