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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002855
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:07:45 PM


Document Has Been Signed on 11/03/2022 01:07 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:DOLCE VITA HOME CAREFACILITY NUMBER:
315002855
ADMINISTRATOR:NATALYA ANDREYEAFACILITY TYPE:
740
ADDRESS:141 HINCKLEY CTTELEPHONE:
(916) 521-5393
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Natalya Andreyeva, Administrator TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Natalya Andreyeva, Administrator, and explained purpose of inspection. LPA observed caregivers Artur Beinoev and Olga Papoean, also present. LPA observed (6) residents to be in their rooms at the start of the inspection. Currently, there is (1) resident on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Updated license to be sent. Prior to initiating today's inspection, LPA completed required COVID-19 protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and-Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, (3) full bathrooms, (3) shower rooms, kitchen, staff room and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters posted. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen and medications and toxins to be secured also.. LPA observed the inside temperature to be 71*F. Fire extinguisher was last serviced 10/12/2022 and facility conducts quarterly fire drills. Discussed vaccination status of residents/staff, eligibility for boosters and updated visitation protocols. Booster flyers provided. LPA observed multiple Covid posters posted throughout as well as other required postings. LPA observed (1) unlocked gate from the inside back patio with covered patio seating. There are no pools or bodies of water. LPA observed copy of RCFE Administrator certificate #6062966740-exp 5/15/2024. Facility offers variety of activities, including art, music, and games. LPA observed ample supply of PPE.

LPA requested an updated copy of LIC500, LIC308 and be provided by 11/10/2022. LPA obtained a copy of the current liability insurance
There are no deficiencies issued during today's inspection.
Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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