<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700906
Report Date: 03/29/2021
Date Signed: 03/29/2021 12:16:41 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:AMITY CARE HOMEFACILITY NUMBER:
342700906
ADMINISTRATOR:NICOLAE, MINODORAFACILITY TYPE:
740
ADDRESS:4822 IMAGE WAYTELEPHONE:
(916) 331-1136
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:6CENSUS: 5DATE:
03/29/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ruth Nicolae, AdministratorTIME COMPLETED:
12:15 PM
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
On 03/29/2021 at 10:00 AM Licensing Program Analyst (LPA) Jasmine McCrory conducted a pre-licensing inspection via facetime due to COVID-19 precautionary reasons with Ruth Nicolae, Administrator, who assisted in conducting this inspection.

LPA and Admin toured the following areas, including but not limited to: common areas, kitchen, bedrooms and bathrooms. At time of inspection all common areas were free from hazards, clean and in good repair. LPA observed that the Fire extinguisher (May 28, 2020) is current and First Aid kit is fully stocked.

Kitchen was clean and in good repair. Facility is prepared to provide (7) seven days of non-perishable food required for emergency shelter in place supplies. The facility has 4 Bedrooms which were found in good repair with required furniture. Water temperature was tested in common bathroom and measured at 107.1 degrees F, water temperature was also tested in the kitchen and measured at 106.9 degrees F, which is within the required range of 105-120 degrees F.

Facility will accept total a capacity of (6) six non-ambulatory residents per the approved fire clearance. All common areas appear to be free from hazards, clean and in good repair. As of this date, the Department has received the fire clearance.

During this inspection, this facility is in compliance and meets the minimum requirements for a Residential Care Facility for the Elderly (RCFE) license. Component III was completed during this visit with Administrator. Pre-licensing Inspection is complete and this facility has no deficiencies.

Exit interview held with Administrator at 12:00 PM and a copy of this report was given via email at the conclusion of the visit.

Application is pending further review at this time.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1