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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002901
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:14:10 PM


Document Has Been Signed on 07/25/2022 03:14 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:AUNT DOTTIE'S PLACEFACILITY NUMBER:
315002901
ADMINISTRATOR:KIDANE, SELAMFACILITY TYPE:
740
ADDRESS:224 SAGEMOOR COURTTELEPHONE:
(707) 480-0342
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Selam Kidane, Administrator TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met with Selam Kidane, Administrator, and explained purpose of inspection. Debi Stryker, Administrator arrived to the facility at approximately 1:00 pm. LPA observed (5) residents to be eating lunch in the common area and (1) resident to be resting in her room at the start of the inspection. The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (6) residents. Currently, there are (3) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask. Also conducted today was an annual inspection for the current license. LPA and Administrator Selam Kidane toured the interior and exterior of the facility including the common areas, resident bedrooms, resident bathrooms (4), kitchen, staff room and laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in the kitchen and locked toxins in the laundry room. LPA observed the inside temperature to be 78*F. Fire extinguisher was last serviced on 11/3/2021. Alarms on all exit doors and .LPA observed the exterior gate to be unlocked from the inside.. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols.. There is a facility van on site that is current with vehicle maintenance and insurance. Facility has emergency supply kits on site. LPA discussed the previously issued notice to residents regarding ownership change and resident paperwork to be completed upon ownership change. LPA discussed topics on Pre-Licensing Facility Evaluation Checklist.

Component III was reviewed during today’s inspection.

It appears the facility is in substantial compliance and there are no deficiencies being noted today.

Exit interview done. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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