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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001747
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:47:43 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:KING ROAD CARE HOMEFACILITY NUMBER:
315001747
ADMINISTRATOR:SHAVLOVSKY, YANAFACILITY TYPE:
740
ADDRESS:5877 KING ROADTELEPHONE:
(916) 660-9947
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 5DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Larissa Shitova- Licensee TIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/01/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Larissa Shitova, 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 contacted licensee 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 were screened by licensee upon entering the facility.

LPA toured the interior and exterior of the facility together with Licensee to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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