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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002991
Report Date: 06/01/2023
Date Signed: 06/02/2023 11:23:14 AM

Document Has Been Signed on 06/02/2023 11:23 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: 4DATE:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Uniqueka LeeTIME COMPLETED:
12:15 PM
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On June 1, 2023 LPA Tryon visited the facility to do a case management visit to check on a bedroom that was changed from previous use. The room in question is at the front of the house to the right of the front door. Previously the door to the room was in the front hallway on the right, right after coming in the front door. The licensee has moved the door to the back hallway right next to the laundry room, and sealed the original door on the front hallway. That is now a wall. The room appears relatively spacious, has a closet and looks very finished. There are currently no residents living in the room. The room was originally a staff room; and will now be a client bedroom. The former office on the front hall will be the staff room.

LPA took pictures of the room. LPA spoke with licensee/Administrator Ana Docmanov by phone. She told me the location of the floor plans and the construction permit in the facility; and LPA took pictures of the large floor plans and obtained a copy of the permit.

At this time the home is waiting for the Fire Department to inspect the facility again to approve the changes.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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