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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701032
Report Date: 10/24/2024
Date Signed: 10/25/2024 08:17:24 AM

Document Has Been Signed on 10/25/2024 08:17 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/
DIRECTOR:		JENNIFER PRICEFACILITY TYPE:
735
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 878-5088
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 15CENSUS: 14DATE:
10/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Jennifer PriceTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this date LPA Tryon visited the facility to follow up on an incident report dated 10-23-24. The report involved a resident switching the liquid in another resident's juice bottle, then sprayed perfume at staff.

LPA visited the facility to follow up, find out further details about the incident and to make suggestions the facility may take to follow up. LPA met with staff Danielle Martin; spoke with supervisor Jesse Williams by phone; and later with CEO Jennifer Price.

Ms. Price agreed to follow up and to modify the Incident Report.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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