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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002841
Report Date: 02/07/2022
Date Signed: 02/08/2022 09:18:52 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:AUBURN VALLEY SENIOR LIVINGFACILITY NUMBER:
315002841
ADMINISTRATOR:DOCMANOV, ANAMARIAFACILITY TYPE:
740
ADDRESS:3800 LORAY LANETELEPHONE:
(916) 757-7057
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:6CENSUS: 5DATE:
02/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Anamaria DocmonovTIME COMPLETED:
03:30 PM
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LPA Tryon visited the facility on 2/7/2022 to conduct a pre-licensing visit. LPA met with applicant AnaMaria Docmonov.
The facility is currently licensed under another licensee and has 5 residents.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, hallways, laundry, yard, garage, storage. The facility appears to be in substantial compliance at this time. The home is very new, clean, well-furnished and spacious. There is a good food supply including 2 days perishable and 7 days non-perishable food, dishes, supplies, utensils, furniture, bedding, linens/towels, etc. Smoke and carbon monoxide detectors are installed and functioning.

LPA reviewed the Inspection Tool pre-licensing section with applicant.

A Component III RCFE Orientation is not necessary at this time, as the applicant has owned and operated multiple facilities in the recent past.

At this time, the facility appears to be in substantial compliance with the regulations.

Report will be forwarded to the Central Application Bureau to continue the licensing process.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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