<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005398
Report Date: 06/09/2021
Date Signed: 06/09/2021 05:33:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 3DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Nadiya Shumiak, administratorTIME COMPLETED:
05:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 06/09/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPAs temperature was taken upon entering the facility.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of resident bedrooms, bathroom, laundry area, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and facility was found to be in substantial compliance at this time.

Upon arrival, LPA observed that staff working was not associated to the facility. Staff file was not available for review. LPA spoke to administrator on the phone and explained that staff was not to be present at the facility as they're not associated and an individual associated would need to take over. A deficiency is being cited as a result of staff working and being present at the facility without being associated.

Administrator arrived at the facility during inspection and LPA observed staff leave.
Exit interview conducted, appeal rights provided, and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASSIONATE SENIOR CARE III
FACILITY NUMBER: 097005398
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:

Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 persons working at the facility which poses an immediate health, safety or personal rights risk to persons in care.
**IMMEDIATE CIVIL PENALTY ASSESSED**
POC Due Date: 06/10/2021
Plan of Correction
1
2
3
4
Letter of understanding that staff should be associated to the facility prior to working.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3