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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700791
Report Date: 06/05/2020
Date Signed: 06/05/2020 10:37:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 0DATE:
06/05/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria MangiucTIME COMPLETED:
10:20 AM
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Licensing Program Analyst(LPA) contacted the facility via telephone due to COVID-19 and pre-cautionary measures. The purpose of this call is conducting an announced prelicensing visit. LPA spoke to Applicant/Administrator Maria Manghiuc. Administrator held the camera to show LPA the facility.

This facility has a fire clearance for five non-ambulatory and one bedridden residents. The main entrance opens to a hallway that leads to the back of the house. On the right of the main entrance, there is a short hallway that leads to two private resident rooms and one full common bathroom. Both resident rooms have exits to the outside. To the left of the main entrance is a hallway that leads to a staff room, two private resident rooms that both have full private bathrooms and exits to the outside, locked laundry room that has an exit to the outside, and the shared resident room that has a full private bathroom and exit to the outside. Bedroom three is designated as the bedridden room. The kitchen, dining, and common areas are in the back of the facility. There are locked cabinets for files and medications. The kitchen has a locked cabinet for sharp knives, cleaning supplies under the sink, and the stove top has a lock on it to prevent it from being turned on. There is an exit to the backyard from the dining area. The backyard has a covered patio. The gate is on the same side as the laundry room.

LPA waived component III orientation because the administrator has prior working experience operating RCFEs.

This facility meets all regulations. LPA is going to submit this report to the application specialist for final review.

LPA is going to email a copy of this report to Administrator and Administrator is to sign, and email a copy back to LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020
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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