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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002290
Report Date: 05/26/2021
Date Signed: 05/27/2021 09:34:32 AM

Document Has Been Signed on 05/27/2021 09:34 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PLEASANT HOME CAREFACILITY NUMBER:
317002290
ADMINISTRATOR:ANA CAIFACILITY TYPE:
740
ADDRESS:7040 LUDLOW DRIVETELEPHONE:
(916) 797-3405
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina Romanova (Licensee)TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 05/26/2021 to conduct a Required - 1 Year Inspection utilizing the infection control domain, LPA met with Irina Romanova (Licensee) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and wore N-95 mask. LPA was screened upon entry.

LPA and Licensee toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) out of five (5) bedrooms, two (2) bathrooms, kitchen, garage and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA conducted interviews with three (3) of five (5) residents and was ensure they were in good health and happy. LPA, staff and Licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
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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