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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700571
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:15:04 PM


Document Has Been Signed on 04/12/2022 03:15 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:VITAE HOME CAREFACILITY NUMBER:
312700571
ADMINISTRATOR:TROSTINSKY, ELAINEFACILITY TYPE:
740
ADDRESS:6882 BRANDY CIRCLETELEPHONE:
(916) 797-6238
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Elaine TrostinskyTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) B. Mirlohi and L. Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Facility Administrator, Elaine Trostinsky and explained the purpose of the visit. Prior to initiating the visit, 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 ensured they used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. Facility has 6 residents 2 of which are on hospice.

Administrator agrees to send in LIC500, liability insurance and LIC610E.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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