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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002219
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:16:13 PM


Document Has Been Signed on 07/25/2022 03:16 PM - It Cannot Be Edited

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:AUNT DOTTIE'S PLACEFACILITY NUMBER:
315002219
ADMINISTRATOR:STRYKER, DEBIFACILITY TYPE:
740
ADDRESS:224 SAGEMOOR COURTTELEPHONE:
(916) 773-2514
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Debi Stryker, Administrator and Selam Kidane, Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Selam Kidane, Administrator, and explained purpose of inspection. Debi Stryker, Administrator
arrived to the facility at approximately 1:00 pm. LPA observed (5) residents to be eating lunch in the common area and (1) resident to be resting in her room at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (6) residents. Currently, there are (3) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility.and the following Personal Protective Equipment (PPE) was worn: surgical mask. Also conducted today was a Pre-licensing inspection for a pending change in ownership.
LPA and Administrator Selam Kidane toured the interior and exterior of the facility including the common areas, resident bedrooms, resident bathrooms (4), kitchen, staff room and laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in the kitchen and locked toxins in the laundry room. LPA observed the inside temperature to be 78*F. Fire extinguisher was last serviced on 11/3/2021. Alarms on all exit doors and .LPA observed the exterior gate to be unlocked from the inside.. Discussed vaccination status of residents/staff, eligibility for second boosters and visitation protocols. All staff are cleared/associated. Administrator certificates current. All required postings and various Covid posters are posted. Facility has van on site that is current with maintenance and insurance. Facility has emergency supply kits on site.
LPA reviewed Infection Control Plan and LPA completed the Infection Control Domain with both Administrators.

There are no deficiencies being cited. Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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