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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002988
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:16:11 PM


Document Has Been Signed on 07/18/2023 01:16 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:ROCKLIN SENIOR LIVINGFACILITY NUMBER:
315002988
ADMINISTRATOR:DOCMANOV, ANAMARIAFACILITY TYPE:
740
ADDRESS:5720 MORNINGSIDE CTTELEPHONE:
(916) 757-7057
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 6DATE:
07/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elena Docmonov, Lead caregiver TIME COMPLETED:
01:15 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 Elena Docmanov, Lead Caregiver (Admin Designee) and explained purpose of inspection. Also present were caregivers, Ethel Haughten and Winnifred Morris Graham. Administrator, Anamaria Docmanov, virtually attended the Comp III portion of the inspection. LPA observed (6) residents present and was advised (2) residents are currently under hospice care. There is currently an approved hospice waiver for (2) residents.

LPA and Administrator Designee toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (3) resident bathrooms with showers, kitchen, office, locked laundry and medication area and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting and the bathrooms to have the necessary grab bars, non-skid flooring, and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps, toxins and medications to be locked in the kitchen using magnetic locks. LPA observed additional locked toxins in the laundry area. LPA observed a covered patio table and chairs and (1) unlocked exit gate in the backyard. (LPA observed maintenance staff to begin to change the handle lock to one that only locks from the outside). The inside temperature measured 78*F. Fire extinguisher was last serviced on 8/23/2022 and all doors have alarms. LPA observed a complete First Aid kit except for tweezers and sufficient PPE and paper supplies. All smoke/monoxide alarms were recently tested by the fire department and were functioning. Water temperature measured 108*F in a bathroom. LPA observed sufficient linens/towels/blankets. LPA observed various required postings posted- Administrator to post Theft & Loss Policy. All staff are fingerprint cleared and associated. LPA observed all staff files to be complete and contain current training documentation, including First Aid/CPR certifications. Resident files were reviewed and observed to contain all required documentation- Administrator to ensure care plans and physician reports are updated at least every 12 months, when required, and all paperwork is updated once new license is issued. Administrator to ensure tweezers are added to the First Aid kit and a small tear in a bathroom window screen tear is repaired. Component III was reviewed during today’s inspection. Pre-Licensing is complete and this facility has no deficiencies.
Exit interview. Copy of report left at facility. LPA to notify to the Centralized Applications Bureau.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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