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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002991
Report Date: 04/19/2023
Date Signed: 04/20/2023 10:34:13 AM

Document Has Been Signed on 04/20/2023 10:34 AM - 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:ROSEVILLE SENIOR LIVINGFACILITY NUMBER:
345002991
ADMINISTRATOR:DOCMANOV, MIODRAGFACILITY TYPE:
740
ADDRESS:6573 ROSE BRIDGE DRTELEPHONE:
(916) 678-2908
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 3DATE:
04/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anamaria Docmanov, ApplicantTIME COMPLETED:
12:00 PM
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On April 19, 2023 LPA Tryon visited the facility to do a prelicensing inspection. LPA met with applicant Ana Docmanov. This is a change of ownership, and the facility currently has 3 residents in care.

LPA toured the facility with applicant including common areas, kitchen, dining areas, living room, hallways, bedrooms, bathrooms, laundry, storage, garage and yard. The house appears to be in good condition, clean and well-furnished.
Food supplies appear adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Facility has adequate supply of dishes, cookware, utensils, etc. as well as hygiene and cleaning supplies. Medications are centrally stored and locked in a cabinet in the kitchen, first aid supplies present. Potentially hazardous substances and items are secured. There are no hazards noted, doors, walkways free of obstruction. Fire extinguisher present and charged, smoke detectors and carbon monoxide detector installed. The yard has plenty of space and a covered sitting area at a table.

LPA reviewed the Pre-licensing section of the CARE Tool with applicant.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies noted.

Since the applicants have owned and operated multiple other RCFE care homes, LPA did not require applicants to complete a RCFE Orientation Component III at this time.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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