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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002872
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:04:51 PM


Document Has Been Signed on 03/04/2022 02:04 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:CENTURY CARE HOMEFACILITY NUMBER:
345002872
ADMINISTRATOR:SOLOVYEV, RALUCA DELIAFACILITY TYPE:
740
ADDRESS:5725 CENTURY WAYTELEPHONE:
(916) 254-9557
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
03/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Alena Tripadush, Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct an unannounced pre-licensing inspection. LPA spoke with caregiver, Shanta "Roxanne" Robinson, caregiver, who contacted
Alena Tripadush, Administrator, by phone, who arrived at 12:15 pm Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering and was wearing: KN95 Mask. LPA observed (6) residents to be eating lunch at the kitchen table and was advised (1) resident is currently receiving hospice services. The facility is currently undergoing a change in ownership. Currently licensed for (6) non-ambulatory residents and has a hospice waiver for (3).

LPA and Administrators toured the interior and exterior of the facility including the common areas, resident bedrooms (6), private bathrooms, shower area, kitchen, and laundry area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout, including hallway night-lights. LPA observed sufficient 7+day non-perishable and 2+ day perishable supply of food on hand. LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been last serviced 7/13/2021. LPA observed the necessary grab bars and non-skid flooring in the shower room/bathrooms and sufficient towels, linens and personal hygiene items/PPE. LPA observed an unopened, new First aid kit with all required supplies. Hot water in the kitchen measured 114* F. LPA observed ramps at the front and back entrance and the backyard pool to be fenced and locked.. LPA observed exit doors to have alarms on them. LPA reviewed and found resident/staff binders to be complete, organized and current. Discussed vaccination status of staff/residents and current Covid visitation protocols. LPA observe games, books and activities on site. Administrator certificate #6048111740- exp 5/29/2022.

Comp III was conducted during today's inspection. LPA to notify analyst in application unit that this pre-licensing is complete and this facility has no deficiencies.

Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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