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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700791
Report Date: 05/27/2020
Date Signed: 05/27/2020 10:00:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:FOOTHILLS SENIOR CAREFACILITY NUMBER:
312700791
ADMINISTRATOR:MANGHIUC, MARIAFACILITY TYPE:
740
ADDRESS:425 KNOWLTON CTTELEPHONE:
(916) 276-2687
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: DATE:
05/27/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria ManghiucTIME COMPLETED:
09:45 AM
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COMP II by CAB successfully completed


Facility Type: RCFE
Application Type: CORP
Capacity: 6
Census (if any clients in care): NO
Method: Telephone at CAB
COMP II Participants: Maria Manghiuc (Applicant/Administrator)

Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program


2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator
certificate, Financial verification, Pre-licensing inspection, Compliance history,
Control of property
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Thai DoanTELEPHONE: (916) 651-1057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020
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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