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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701038
Report Date: 05/27/2021
Date Signed: 05/28/2021 02:03:18 PM

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:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
05/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marina IancuTIME COMPLETED:
11:58 AM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility announced on 05/272021 to conduct an announced prelicensing visit. LPA met with Applicant/Administrator Marina Iancu, and explained the purpose of the visit. Prior to initiating the prelicensing 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; contacted applicant and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator at the front door.

This facility has a fire clearance for six non-ambulatory residents. This facility has six private resident rooms and an office/licensee living area on the second floor. The main entrance opens to a small foyer. There is a private resident room to the left and right of the main entrance. The is a hallway in front of the main entrance that leads to three private resident rooms and a full common bathroom. The largest room at the end of the hallway has an exit to the outside and a full private bathroom. To the right of the main entrance past the resident room is a door leading to the main common area that has the kitchen, dining, and living room. To the left and slightly across from the kitchen is a short hallway that has the sixth private resident room that has an exit to the outside, full common bathroom, laundry room that has a door leading to the garage, and the staircase that leads upstairs.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MISTY WOOD SENIOR CARE LLC
FACILITY NUMBER: 312701038
VISIT DATE: 05/27/2021
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The garage is going to be used for storage. Administrator stated there is going to be awake staff at all times. The backyard was inspected. There is a locked shed and gate leading to the front yard on the same side as the garage. There are locked cabinets in the kitchen for sharp knives. The oven has a lock built into it so the knobs do not have to be removed when not in use as long as the lock is turned on. The medications are going to be stored in a locked closet.

LPA waived the component III orientation because Administrator already operates another facility. Multiple topics were discussed during this visit.

This facility meets regulations. LPA is going to submit this report to the applications specialist.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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