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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920089
Report Date: 12/28/2023
Date Signed: 12/28/2023 10:34:35 AM


Document Has Been Signed on 12/28/2023 10:34 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:FANDANGO HOME CAREFACILITY NUMBER:
315920089
ADMINISTRATOR:TATISHVILI, MARINAFACILITY TYPE:
740
ADDRESS:5496 FANDANGO LOOPTELEPHONE:
(916) 222-0736
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
12/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marina Tatishvili, AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with Licensee and Administrator Marina Tatishvili during today's visit.

Facility was inspected both indoors and outdoors. LPA inspected 6 resident bedrooms, 3 bathrooms, common living areas, garage and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible and an outdoor covered seating area is available. First aid kit was present in the facility. Centrally stored medications will be locked in the closet near the front door. 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. Hot water was checked and found to be 118 degrees Fahrenheit. Fire clearance was granted on 11/01/2023 for 6 non-ambulatory. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use. Liability insurance will be purchased once facility is licensed.

Competent III was waived. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted and copy of report provided to licensee.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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