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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003566
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:51:16 PM


Document Has Been Signed on 03/12/2024 03:51 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LAKE VIEW RESIDENTIAL CAREFACILITY NUMBER:
097003566
ADMINISTRATOR:PASHINA, ELENAFACILITY TYPE:
740
ADDRESS:2932 ABERDEEN LANETELEPHONE:
(916) 933-1230
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator Alex LutsukTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Lavinia Muscan arrived unannounced on 03/12/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and Caregiver Oksana Gutsu toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Files reviewed. In the areas toured, there were no health or safety violations observed. All required posting were observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report was printed and left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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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