342700766-8-20-2020-27-AS-KGAO-BSNV8E-20200820161237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700766
Report Date: 08/20/2020
Date Signed: 08/20/2020 04:14:27 PM

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:	YELLOWTAIL HOME CARE		FACILITY NUMBER:	342700766
ADMINISTRATOR:	LUI, YING		FACILITY TYPE:	740
ADDRESS:	8513 YELLOWTAIL WAY		TELEPHONE:	(415) 601-6107
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 4	DATE:	08/20/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ying (Ruby) Liu		TIME COMPLETED:	10:45 AM

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	Licensing Program Analyst (LPA) Kevin Gasendo and LPA Kerry Hiratsuka conducted a scheduled pre-licensing inspection via tele-visit on 8/20/2020. Due to COVID-19 and precautionary measures, this inspection was done over Facetime. This is a change of ownership, and there is a census of 4 residents. LPAs and Administrator toured the interior and exterior of the facility. Areas covered included the residents' bedrooms and bathrooms, the kitchen, living room backyard and laundry room. LPAs observed the facility to be clean, in good repair and to have sufficient furnishings in common areas and each of the bedrooms. All bathrooms are equipped with non-skid floor mats, grab bars, soap and paper towels. LPAs observed sufficient lighting throughout the facility. LPAs viewed the front yard and back yard to have no steps or stairs, and large backyard area with a locked shed and patio furniture. Facility had all the required postings, including the front door for COVID-19 and a bulletin board near the front door. Kitchen was sufficiently stocked. LPAs witnessed an alarm sounding for when exterior doors are opened and closed, as well as a functioning smoke detector and carbon monoxide detectors. Administrator locked knives in her office, which has an employees only sign on the door and is locked. LPAs checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. (Cont. on 809-C)

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Gasendo	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

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: YELLOWTAIL HOME CARE	FACILITY NUMBER: 342700766
	VISIT DATE: 08/20/2020

NARRATIVE

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LPAs viewed a locked medications cupboard in the laundry room.

Cleaning supplies/chemicals were locked in two places: one was underneath a bathroom sink that was chain-locked, and the other in a cabinet chain-locked in the office.

The office will be locked, and will hold staff files and resident files.

Component III was done during today's inspection.

LPA did not find any deficiencies during this visit. LPA is going to submit this application to the application's specialist for their final review.

A copy of this report will be provided to the facility administrator via email. A copy will be sent to the facility via email and is to be signed and returned to Community Care Licensing Division. Signature for facility representative shall be on the hard copy of this report.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Gasendo	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

LIC809 (FAS) - (06/04)

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