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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005398
Report Date: 03/02/2021
Date Signed: 03/02/2021 04:52:19 PM

Document Has Been Signed on 03/02/2021 04:52 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
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:
03/02/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nadiya Svityashchuk (Admin/Licensee)TIME COMPLETED:
03:00 PM
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On 3/2/2021 at 1:30p.m. a virtual office meeting was had between Community Care Licensing Division (CCLD) and Nadiya Svityashchuk (Admin/Licensee) of Compassionate Senior Care III. Today’s office meeting was done via WebEx due to COVID-19 precautionary measures. During today’s office meeting, the following individuals were present: Licensing Program Analyst (LPA) Konnor Leitzell; LPA Danyle Wolter; LPA Michael Smith; Licensing Program Manager (LPM) Troy Ordonez; and Regional Manager (RM) Alycia Berryman.

Today’s meeting was called to discuss reporting requirements and speak about compliance issues had with the facility. During the call, the following was discussed:
  1. Facility not ensuring CCLD and County Department of Public Health were notified of the COVID-19 outbreak at Compassionate Senior Care II in early January.
  2. The recent virtual visit conducted regarding COVID-19 procedures and practices at Compassionate Senior Care II.
  3. Compliance with screening visitors and surveillance testing of staff.
  4. Face Covering compliance.
  5. Recent Provider Information Notices and Applicable laws and regulations.
  6. Administrator’s hours at each three facilities.
  7. Staffing concerns.

Cont. LIC809C
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 097005398
VISIT DATE: 03/02/2021
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Licensee agrees to the following:
  • Provide a Plan of action to LPA regarding the discussions above.
  • Provide In service training for staff regarding reporting requirements.
  • Implement a weekly schedule to keep track of hours the administrator and staff are at the facility.
  • Identify a designated administrator for facility by COB 3/19/2021.
  • Hire administrator for Compassionate Senior Care III by June 1, 2021.
  • Submit weekly screening log for residents, staff and visitors from March 2, 2021 – June 1, 2021.

The department will be taking the following actions:
  • Increased monitoring of the facility will take place.
  • Schedule Infections Control Training for Facility.

Exit interview was conducted, report is provided to Administrator via email due to COVID-19 Precautionary measures. LPA is to send report with a read receipt to ensure delivery.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC809 (FAS) - (06/04)
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