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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005115
Report Date: 07/06/2022
Date Signed: 07/06/2022 05:04:18 PM


Document Has Been Signed on 07/06/2022 05:04 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:FAIR OAKS HOME CARE FOR THE ELDERLYFACILITY NUMBER:
347005115
ADMINISTRATOR:LYUDMILA PALAMARCHUKFACILITY TYPE:
740
ADDRESS:8119 OAHU DRIVETELEPHONE:
(916) 962-7458
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cristina Gudumac, caregiver/Administrator Designee,TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Anastasia Bondarenko, caregiver, who contacted Cristina Gudumac, caregiver/Administrator Designee, who arrived at 2:45 pm. LPA explained purpose of inspection and was advised Administrator was out of town currently. LPA later spoke to Lyudmila Palamarchuk, Administrator, by phone. LPA observed (3) residents to be watching television in the common area and (2) residents to be in their rooms. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3) residents. Currently, there are (0) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator Designee toured the interior and exterior of the facility, including (6) private resident bedrooms, (2) bathrooms, kitchen, common areas, locked laundry area, and office area. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 76* F. Fire extinguisher last serviced 12/2/2021. LPA observed secured toxins, medications and sharps and sufficient 2+day perishable/7+day non-perishable food. First aid kit on site. Exit doors have alarms on them. LPA observed soap, sanitizer, hand-washing poster and trash cans with lids in the bathrooms. Discussed vaccination status of residents/staff, eligibility for second boosters and visitation protocols per PIN 22-07. All staff are cleared/associated. Administrator certificate #6016244740- exp 1/26/2022. Administrator stated renewal documentation and payment were received in January 2022, and she always receives her renewal certificate on/around August/September. Administrator to follow up with the Department and provide status of renewal by 7/15/2022.

LPA requested an updated copy of LIC500, LIC308 and a copy of the current liability insurance by 7/15/2022.

Exit interview. There were no deficiencies observed during today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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