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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002845
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:45:27 AM


Document Has Been Signed on 03/16/2022 11:45 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PINNACLE HOME CARE 2FACILITY NUMBER:
315002845
ADMINISTRATOR:DAVTYAN, LUSINEFACILITY TYPE:
740
ADDRESS:1225 CANEVARI DRIVETELEPHONE:
(916) 771-9420
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
03/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lusine "Lucy" and Ara "Eric" Davtyan TIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 03/16/2022, to conduct a prelicensing visit. This facility is undergoing a change of ownership. LPA met with Facility Applicants Lusine "Lucy" and Ara "Eric" Davtyan, and current Licensee Jennifer Lui, and explained the purpose of the visit. Prior to initiating the visit, 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. LPA ensured they washed hands just after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Applicant.

This facility has a fire clearance for all non-ambulatory residents. The main entrance opens into the main sitting area on the right. The caregiver room is just past the main sitting area and past that is the kitchen, dining, and an area used for an office type setting. There is a hallway on the left of the main entrance that leads to the resident rooms. There are two shared and two private rooms. One of the shared rooms has an exit to the outside and a full private bathroom. There are two full common bathrooms. One bedroom is located past the area that is used as the laundry area. There is a locked closet for all cleaning chemicals, resident files, and medications. There is a door leading to the garage from the hallway. The garage is off-limits to the residents. The backyard has a gate to the front yard on the same side as the garage.


Component three orientation was conducted today.

Multiple topics discussed

This facility meets licensing requirements. LPA is going to submit this to applications specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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