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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920133
Report Date: 05/20/2024
Date Signed: 05/20/2024 10:21:31 AM

Document Has Been Signed on 05/20/2024 10:21 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALL SEASONS GOLDEN GATEFACILITY NUMBER:
345920133
ADMINISTRATOR/
DIRECTOR:		MOLITVENIK, TOLIYFACILITY TYPE:
740
ADDRESS:9470 GOLDEN GATE AVE.TELEPHONE:
(916) 776-6665
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 0DATE:
05/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Toly MolitvenikTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 05/20/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility announced to conduct a Pre- Licensing visit. LPA met with Administrator, Toly Molitvenik and explained the purpose of the visit. Co-administrator, Galina Chikivchuk was also present during this visit. The facility currently has no residents during today's inspection. Facility has a fire clearance for six (6) bedridden residents (dated- 04/23/24).

LPA and Licensee conducted a tour of the facility. Areas toured include but are not limited to: six (6) residents bedrooms, seven (7) bathrooms, common areas, kitchen, dining area and backyard. LPA observed the facility to be clean and sanitary. The food supply is within compliance, two (2) days of perishable and seven (7) days of non-perishable food items. Smoke and carbon monoxide detectors are operational. The Fire extinguisher was last serviced on 01/18/24. Grab bars were present at the toilets and in the showers. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. Facility's temperature was 72 degrees Fahrenheit during inspection. Hot water temperature was observed to be 107 degrees Fahrenheit, which is within the regulation range of 105-120 degree. First aid kit found to be complete.

LPA observed the facility to have the required posters of Community Care Licensing Division and Long Term Care Ombudsman.


Pre-licensing passed and Component III was waived. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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