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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005398
Report Date: 02/24/2021
Date Signed: 02/24/2021 10:57:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COMPASSIONATE SENIOR CARE IIIFACILITY NUMBER:
097005398
ADMINISTRATOR:SHUMIAK, NADIYAFACILITY TYPE:
740
ADDRESS:4075 ARENZANO WAYTELEPHONE:
(916) 542-7733
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 5DATE:
02/24/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mariya LovyanTIME COMPLETED:
11:00 AM
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Case management visit regarding Covid 19 concerns. LPA was greeted at the front window, adjacent to the front door, by Mariya Lovyan, caregiver. LPA noticed that the caregiver was not wearing a mask as required by PIN 21-12-ASC. Upon the front door being opening, the identified caregiver was wearing a mask.

Upon inquiry, LPA was informed that they do not have any Covid positive residents and everyone has received their vaccination except 1 resident who's family refused. (See confidential 812)

Facility reports that there have been no Covid 19 cases in the facility since the pandemic started to current.

See Advisory Notes - Technical Violation
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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