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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700562
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:35:27 PM


Document Has Been Signed on 09/07/2023 03:35 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BONITA HOME CARE 4FACILITY NUMBER:
312700562
ADMINISTRATOR:POLYAKOVA, ALENAFACILITY TYPE:
740
ADDRESS:1732 WOODHAVEN CIRCLETELEPHONE:
(916) 628-0066
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Alena and Anna PolyakovaTIME COMPLETED:
03:45 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Co-Administrator Alena Polyakova and Anna Polyakova arrived during the visit. This facility has a fire clearance for six non-ambulatory residents. The main entrance opens to a sitting area. There is a private resident room with a full private bathroom and an exit to the outside on the immediate left of the main entrance. There is a hallway on the right side leading to three private resident rooms, one shared resident room, locked laundry room that leads to the garage, and one full common bathroom. The shared resident room has an exit to the outside and a full private bathroom. The medications, resident, and staff files are going to be locked in cabinets in the hallway. Past the first sitting area leads to the second sitting, dining, and kitchen area. The backyard has locked shed and there is a gate on the same side as the garage. The garage is going to be used for storage.

-two resident files were reviewed.
-two staff files were reviewed
-several topics were discussed

The following shall be updated and submitted to Community Care Licensing by 09/25/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility


no deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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