<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001747
Report Date: 01/20/2022
Date Signed: 01/20/2022 01:22:48 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: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: 4DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Larisa Shitova- Licensee TIME COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 1/20/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility 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 completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Facility staff notified Licensee, Larisa Shitova, that LPA is at the facility to conduct an annual inspection. Licensee is on the way to the facility and will arrived at a later time.

LPA toured the interior and exterior of the facility together with facility staff 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. Licensee arrived at the facility. 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: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1