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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700906
Report Date: 03/09/2022
Date Signed: 03/09/2022 10:20:46 AM


Document Has Been Signed on 03/09/2022 10:20 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ruth NicolaeTIME COMPLETED:
10:35 AM
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Licensing Program Analyst Talwinder Bains arrived at the facility unannounced on 03/09/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator , Ruth Nicolae , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA wore the following Personal Protective Equipment (PPE) during today's visit: N-95 masks. LPA was screened by administrator before entry to facility.

LPA and Administrator toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, four (4) bedrooms , two (2) bathrooms, medication closet , staff break room, garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today's inspection.
Exit interview conducted and copy of report left at the facility.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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