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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002901
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:58:06 PM


Document Has Been Signed on 07/11/2023 04:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Selam Kidane, Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full inspection care tool. LPA met with Lisa Neil, caregiver, who contacted Selam Kidane, Administrator, who arrived at the facility shortly. LPA explained the purpose of today's inspection. LPA observed (3) residents in the common areas and (2) residents in their rooms at the start of the inspection. Currently, there is (1) resident on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (2) resident bathrooms, staff room, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food in the kitchen. Sharps are locked with the medications in a designated closet, and all toxins are locked in the laundry area. LPA observed sufficient PPE/incontinent supplies and linens/towels/blankets. The inside temperature measured 79*F and the water heater is set at 120*F. The fire extinguisher was last serviced 11/13/22 and fire to conduct their annual inspection this month. There is additional food and emergency supplies in the garage. (1) smoke/monoxide alarm was tested and found to be working correctly. Facility conducts quarterly emergency drills. There is (1) unlocked outside gate and a covered patio dining set. LPA reviewed (2) of (5) resident files and found them to be complete and current. LPA and Administrator reviewed ordered medications to those being administered for (1) resident and found no discrepancies. LPA reviewed (2) staff files and found them to contain current training documentation, including First Aid/CPR certification. RCFE Administrator certificate #6060726740- posted- exp 10/23/23. Administrator is in the process of renewing it. LPA observed all required postings to be posted and the Emergency Disaster Plan and Infection Control Plan to be readily available for staff in binders. All staff are cleared and associated to the facility. An updated copy of liability insurance was obtained (exp 4/28/24). LPA requested an updated copy of LIC308 and LIC500 be sent to the Department by 7/18/23.

There are no citations issued. Exit interview. Copy of report provided to Administrators.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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