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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005398
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:01:20 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: 0DATE:
10/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nadiya SvityashchukTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility on 10/12/2021 to conduct a Case Management Inspection proceeding the closure of the facility. LPA met with Licensee, Nadiya Schmiak, and explained the purpose of the visit. Prior to initiating the Case Management 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. LPA the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA ensured to apply hand sanitizer before entering the facility.

LPA observed that there were no residents at the facility . LPA toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, four (4) bathrooms, kitchen, and backyard.



LPA advised Licensee to mail the original License to the Regional Office and that the facility will be closed in the system as of 10/12/2021. A copy of this report has been emailed to the Licensee and the Licensee was advised that a signed copy of this report shall be submitted to Community Care Licensing Department (CCLD) within 10 days of receipt of this report.

Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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