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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002882
Report Date: 03/09/2022
Date Signed: 03/09/2022 01:38:34 PM


Document Has Been Signed on 03/09/2022 01:38 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:NADIA'S CARE HOME LLCFACILITY NUMBER:
315002882
ADMINISTRATOR:MURGOI, NADEJDAFACILITY TYPE:
740
ADDRESS:2728 WESTVIEW DRIVETELEPHONE:
(916) 775-9575
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
03/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator- Nadejda Murgoi TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility on 3/9/2022 to conduct a Pre-Licensing inspection. LPA met with Administrator, Nadejda Murgoi. Prior to initiating the Pre-Licensing inspection, 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 and LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by Administrator upon entering the facility.

This is a change in ownership and currently has six (6) residents living in the facility. LPA toured the facility with Administrator. The indoor and outdoor passageways were free of obstruction. The facility has a total of six (6) bedrooms and two (3) and half bathrooms. One bedroom is being used as staff's room. There is an exit in bedroom number two (2), four (4), and six (6) that leads to the backyard. LPA notified Administrator that no locks are permitted on bedroom number three (3) four (4), and six (6). A door alarm is to be set up in the bedrooms with an exit to the backyard for Dementia residents. LPA observed common areas such as: living room, kitchen, residents' bedrooms, bathrooms, laundry room, and backyard. LPA observed knives/sharps were locked in the kitchen pantry. LPA observed toxic and cleaning supplies locked underneath the kitchen sink. LPA observed the require furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. Hot water temperature was measured in residents' bathroom at 119 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer located in the kitchen cabinet. LPA observed centrally stored medication to be locked. LPA observed one (1) fire extinguisher in the kitchen mounted on wall. LPA observed fire detectors and carbon monoxide.

Component III presentation conducted with Administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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