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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920006
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:06:47 PM


Document Has Been Signed on 07/18/2023 03:06 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:ABLOOM SENIOR LIVINGFACILITY NUMBER:
315920006
ADMINISTRATOR:DROBENYUK, YURIYFACILITY TYPE:
740
ADDRESS:100 KENMARE CTTELEPHONE:
(916) 621-9441
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: DATE:
07/18/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Yuriy DrobenyukTIME COMPLETED:
02:45 PM
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Component II completion: Successful
Facility Type: RCFE
Application Type: CHOW
Capacity: Census (if any clients in care): 5
COMP II Participants: Yuriy Drobenyuk, corp member/administrator
Interview Method: Telephone interview

On July 18, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
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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