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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002841
Report Date: 01/05/2024
Date Signed: 01/09/2024 11:08:51 AM


Document Has Been Signed on 01/09/2024 11:08 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anamaria DonmanovTIME COMPLETED:
04:30 PM
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On 1/5/2023 LPA Tryon visited the home to do an annual visit. LPA met with Licensee Anamaria Docmonov.

LPA toured the facility including common areas, kitchen, food supplies, laundry, medication area, bedrooms, bathrooms, hallways. The facility is clean, in good condition and well-furnished.

Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable. The facility has a good supply of PPE, hand sanitizer, soaps, paper products ,etc.

Appropriate postings, posters such as client's rights, reporting agencies, emergency plans, etc. are present.

LPA reviewed 2 of 6 resident files and files for all staff. Files appear complete and accurate.

LPA reviewed the CARE Tool with licensee.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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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