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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005948
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:28:26 PM

Document Has Been Signed on 09/28/2021 12:28 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ABLEFACILITY NUMBER:
317005948
ADMINISTRATOR:POURARIAN, AMITISFACILITY TYPE:
775
ADDRESS:8200 SIERRA COLLEGE DTELEPHONE:
(916) 276-6777
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 30CENSUS: 0DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Amitis Pourarian- Administrator TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/28/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Amitis Pourarian, 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 and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA notes that the license is still current and active. However, the facility is not in operation at this time as a Day Program.

LPA toured the interior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas and two bathrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for Administrator to submit documents to Community Care Licensing when the facility plans to operate and accept clients.
  • Mitigation Plan LIC 808
  • Administrator's Certificate
  • Designation of Administrative Responsibility LIC 308
  • Liability Insurance

Exit interview. Copy of report provided to facility representative.

No deficiencies issued.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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