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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001759
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:53:40 AM


Document Has Been Signed on 11/29/2022 11:53 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:TAJ RESIDENTIAL CAREFACILITY NUMBER:
317001759
ADMINISTRATOR:MANN, SURINDERFACILITY TYPE:
740
ADDRESS:7144 LUDLOW DRIVETELEPHONE:
(916) 780-4541
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Gina Judge and Surinder MannTIME COMPLETED:
12:10 PM
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On 11/29/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required- 1 Year annual. LPA met with Assistant Administrator, Gurdip "Gina" Judge, and explained the purpose of the visit. Additionally, LPA observed the following staff present: Administrator, Surinder Mann, and caregiver, Beverley Rowe. Prior to today's inspection, LPA ensured she applied hand sanitizer and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility currently has (6) residents and (1) resident on hospice services. The facility has an approved hospice waiver of four (4).

LPA and Assistant Administrator toured the interior and exterior of the facility including bathroom, (5) resident bedrooms, caregiver room, laundry room, kitchen, backyard and common area. LPA observed (3) residents to be in the common area, and (2) residents to be in their private rooms. LPA was informed (1) resident was out of the facility for health class. In the areas toured, no immediate health and safety risk were observed. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishables foods located in the garage. Fire extinguishers was observed to be last serviced on 4/8/2022. LPA observed the facility to have documentation of visitation screening. LPA observed the facility to have the Ombudsman and CCLD posters to be posted in the hallway. LPA observed paper towels, soap and hand washing signs in bathroom. LPA observed the facility to have COVID-19 signs to be posted throughout the facility. LPA observed sharps, toxics and medication to be locked and secured. LPA and Assistant Administrator completed the infection control domain together, and at this time the facility was found to be at substantial compliance.

LPA was provided copies of Administrator Certificate, LIC 308 and current Liability Insurance.
As a result of today's inspection, no deficiencies were observed.

Exit interview was conducted. A copy of report was left at facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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