<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002765
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:36:40 PM

Document Has Been Signed on 08/20/2024 12:36 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 RESIDENCE IIFACILITY NUMBER:
185002765
ADMINISTRATOR/
DIRECTOR:		MOTTS, ALICIAFACILITY TYPE:
735
ADDRESS:116 SOUTH MESATELEPHONE:
(530) 257-2956
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 6CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator, Alicia MottsTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 20, 2024 at approximately 10:45 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Zamora Residence II for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Alicia Motts and was granted access into the facility.

LPA and Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. Carbon monoxide detectors were tested and found to be operational during the inspection. 3 out of 4 smoke detectors were removed by the clients in the facility (See LIC 9102-Technical Violation). LPA observed new smoke detectors ready to be installed. Licensee is in the process of installing the smoke detectors today. Water temperature in facility bathroom measured at 105 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. 2 out of 2 medication orders were reviewed and found to be in compliance. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to clients in care. There was a supply of linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of client bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility.

(Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ZAMORA RESIDENCE II
FACILITY NUMBER: 185002765
VISIT DATE: 08/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Emergency Disaster Plan was discussed with the Administrator. Emergency Disaster drill was last conducted on July 2024. LPA observed a generator inside the garage and ready to use in case of a power outage. LPA reviewed 3 out of 3 staff files and found those to be appropriate during the review. LPA reviewed 4 of 4 client files and found those files to be appropriate during the review.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Control of Property
Register of Clients

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted, and a copy of this report was printed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3