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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002045
Report Date: 06/29/2021
Date Signed: 06/29/2021 04:42:51 PM

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:COUNTRY OAKS MANORFACILITY NUMBER:
347002045
ADMINISTRATOR:ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 517-9597
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Alexsander Molitvenik, administratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 06/29/2021 to conduct a case management visit. Prior to initiating the case management, 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, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entry. LPA met with administrator Alexsander Molitvenik and explained the purpose of the visit.

LPA requested a copy of residents (R1) admission agreement be sent to Community Care Licensing (CCL) by close of business 06/29/2021. LPA also obtained updated contact information for the facility as well.

No deficiencies are being cited as a result of today's visit.
Exit interview conducted and copy of report to be emailed to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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