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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920006
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:48:53 AM


Document Has Been Signed on 08/03/2023 11:48 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 5DATE:
08/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yuriy Drobenyuk, AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with licensee Yuriy Drobenyuk during today's visit.

Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 3 bathrooms, 1 staff room, common living areas, garage and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in the closet. The facility has adequate lighting throughout. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 05/05/2023 for 6 non-ambulatory. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use. LPA reviewed 1 resident and 1 staff file. LPA observed all required documents in resident and staff files.

Competent III was completed during today's inspection with licensee. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted and copy of report emailed to licensee.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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