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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700518
Report Date: 11/09/2020
Date Signed: 11/12/2020 09:43:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A PROMISE TO MOMFACILITY NUMBER:
342700518
ADMINISTRATOR:LISA HERFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 606-4608
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 5DATE:
11/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MhongYeng ThaoTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/9/2020 at 10:00am to conduct a health and safety check on the residents. LPA met with Rosa Garcia-Davalos Caregiver and stated the purpose of the visit. Rosa Garcia-Davalos began working with the facility on 11/2/2020. During a research, LPA did not observe Rosa Garcia-Davalos to be fingerprinted or associated to the facility. LPA contacted Licensee Mike Her regarding the staff. Mike Her indicated that another staff MhongYeng Thao, Caregiver will arrive shortly. MhongYeng Thao arrived within 15 minutes to assist with todays visit.

LPA toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 5 residents receiving care and supervision. Three were participating in a group activity. One was exploring the home and one was in the hospital during this visit. The fire extinguishers, carbon and smoke detectors were present.

LPA observed 2 day perishables and 7 day non-perishables. The hot water measured at 135.8*F which is not within the required range of 105-120*F. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F. LPA observed health and safety concerns during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A PROMISE TO MOM
FACILITY NUMBER: 342700518
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited

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Maintenance and Operation Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by:
Based on the Licensee did not ensure the hot water temperature was between 105-120 degrees. This possess an immediate health and safety risk to residents in care.
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Type A
11/10/2020
Section Cited

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Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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This requirement is not met as evidenced by:
Based on the Licensee did not ensure the staff was fingerprint cleared and associated to the facility prior to working. This possess an immediate health and safety risk to residents in care.
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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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
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