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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700791
Report Date: 06/09/2021
Date Signed: 06/10/2021 08:13:54 AM

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:FOOTHILLS SENIOR CAREFACILITY NUMBER:
312700791
ADMINISTRATOR:MANGHIUC, MARIAFACILITY TYPE:
740
ADDRESS:425 KNOWLTON CTTELEPHONE:
(916) 276-2687
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Reva Radway (Designated Admin)TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/9/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Reva Radway (Staff) and explained the purpose of the visit. Prior to initiating the annual 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; and asked facility staff risk assessment questions. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by Colletta Salmon (Staff).

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) of five (5) resident bedrooms, four (4) of four (4) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Mihnea Manghiuc (Admin Husband) completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is to send facility information regarding PIN 21-28ASC and Fit Testing resources.

LPA is requesting the following documents to be submitted to CCLD by COB 6/18/2021:
Designation of Administrative Responsibility (LIC 308); Personnel Report (LIC 500); Proof of Liability Insurance.

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: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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