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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001689
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:18:21 AM


Document Has Been Signed on 09/25/2024 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:TAJ RESIDENTIAL CARE IIFACILITY NUMBER:
315001689
ADMINISTRATOR:IGOR KOSTHANDINOVICFACILITY TYPE:
740
ADDRESS:8289 HORNCASTLE AVENUETELEPHONE:
(916) 772-1547
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gurdip Judge, AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete an annual inspection. LPA met with Administrator Gurdip Judge during today's inspection.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 1 staff room, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a pool in the backyard with a gate surrounding it and a locked gate. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 3 of 5 resident files and 2 staff files. LPA reviewed medications of three residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. LPA observed a copy of current liability insurance.

No deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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