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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002901
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:06:56 PM


Document Has Been Signed on 07/25/2024 01:06 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:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:CaregiverTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/25/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator, Selam Kinade, arrived to assist.

LPA toured the interior and exterior of the facility together with Admin to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean. One resident interviewed expressed satisfaction with care assistance.

LPA reviewed 5 resident files. Files are complete and well organized.

LPA reviewed 2 staff files. Files are complete.

Several topics and resources discussed.

LPA requested copies of : LIC 308 designations, LIC 500, Infection control plan and liability insurance certificate. \

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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