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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002039
Report Date: 05/01/2024
Date Signed: 05/01/2024 01:55:13 PM

Document Has Been Signed on 05/01/2024 01:55 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:ZAMORA RESIDENCEFACILITY NUMBER:
185002039
ADMINISTRATOR/
DIRECTOR:		MOTTS, ALICIAFACILITY TYPE:
735
ADDRESS:406 RUSSELL AVENUETELEPHONE:
(530) 251-8442
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 6CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Administrator- Alicia Motts TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 05/01/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Alicia Motts and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed each bedroom to have all the required furnishings, working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 115 F. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the need for an updated emergency disaster plan. LPA observed emergency disaster drills conducted quarterly.

LPA reviewed a total of four (4) residents' files and three (3) staff files. Resident files contained all of the required documentation. Two staff files missing a completed Health Screening Report, and one staff file missing a TB clearance.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/01/2024 01:55 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 05/01/2024 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ZAMORA RESIDENCE
FACILITY NUMBER: 185002039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in chemical toxins were found in two locations within the facilit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Adminstrator will move all toxic chemicals in the garage and send the LPA confimations of this change.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three staff files reviewed did not include the health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Adminstrator will ensure that all staff complete a Health Screening before beinging employment.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/01/2024 01:55 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 05/01/2024 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ZAMORA RESIDENCE
FACILITY NUMBER: 185002039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in one out of three staff files reviewed did not include a TB test documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Administrator will ensure that all staff have a completed TB test before starting employment.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4