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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701032
Report Date: 09/20/2021
Date Signed: 09/21/2021 11:34:45 AM

Document Has Been Signed on 09/21/2021 11:34 AM - 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:AMI HOUSING, INC.FACILITY NUMBER:
312701032
ADMINISTRATOR:LIBBY, SHANEFACILITY TYPE:
735
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 878-5088
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 15CENSUS: DATE:
09/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shane Libby and Rachael NobleTIME COMPLETED:
04:15 PM
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On 9/20/21 LPA Tryon arrived at the facility to complete a pre-licensing visit. LPA met with Libby Shane and Rachael Noble.. . The home has passed fire clearance and is ready to occupy.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, office, storage, yard. There is central medication storage in the office The home is clean and in good repair. No hazards were noted, there is no pool in the yard. Windows, doors, walls, screens, floors are in good condition. Temperature in the facility was comfortable. There are no stairways or ramps in the client area of the facility. There is a stairway that goes down stairs to a staff apartment that will not be accessible to residents Carbon monoxide detectors installed and functioning as well as a fire alarm and sprinkler system. Client bedrooms are furnished with appropriate furniture, have plenty of storage/dresser/closet space. Beds with mattresses, pads, bedding present. There are adequate bathroom facilities for 15 residents. There are nightlights in the hallway. The home has appropriate hygiene supplies, bedding, towels, etc. Kitchen is in good condition, adequate supply of dishes, utensils, pots and pans, etc. There is adequate storage for personnel and client records in the office. Emergency exit plan posted, LIC 610. Personal rights posted, complaint poster.
There is adequate space in the yard for client activities and two sitting rooms in the house. Home has activity supplies.
First aid supplies present. Washer/dryers present. The home has an operating land-line telephone, emergency lighting available. Vehicle to be used for residents is new, licensed, appropriately insured and in good condition.
At this time the home appears to meet regulations.

Component III of the CCLD ARF Orientation was reviewed and completed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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