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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701032
Report Date: 07/28/2023
Date Signed: 08/14/2023 08:57:36 AM

Document Has Been Signed on 08/14/2023 08:57 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Danielle MartinTIME COMPLETED:
04:30 PM
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On 7/28/2023 LPA Tryon visited the facility to conduct an annual visit. LPA was greeted by staff.
The facility currently has 3 residents. LPA spoke with Administrator Shane Libby by phone while at the facility. There have been residents in the house for about 2 weeks now.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, yard, storage. The house is separated into two separate "wings" with bedrooms on each end.
Food supplies are appropriate to meet the requirement of 2 days perishable and 7 days non-perishable. Sharp knives are locked in a kitchen cupboard. At this point cleaners are stored in a locker in a locked room that only staff has access to. The home has plenty of dishes, flatware, pots, pans, storage dishes, etc. Medications are centrally stored and locked in the staff office. There are activities such as TV, videos, games and so forth available.
The house was clean, nicely furnished and decorated.
There were 3 staff present when LPA arrived, and 3 residents. One staff left after my arrival.

At this point, LPA ran out of time, and will need to come back at a later date to finish the CARE Tool.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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