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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700906
Report Date: 03/30/2023
Date Signed: 03/30/2023 12:41:19 PM


Document Has Been Signed on 03/30/2023 12:41 PM - 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, 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: 2DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Co-Administrator, Ruth Nicolae TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full inspection care tool. LPA met with Co-Administrator, Ruth Nicolae, and explained purpose of inspection. LPA observed (2) residents to be in their rooms at the start of the inspection. LPA completed the required COVID-19 Department protocols, was screened upon entry to the facility and was wearing a surgical mask. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently, there is (1) resident on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (2) private resident bedrooms, (2) shared resident bedrooms, (2.) resident bathrooms, staff room, kitchen, and laundry. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. LPA observed the door to be locked to the kitchen since there are sharps and toxins; however, there were fruit and snacks accessible on the kitchen counter. Administrator to purchase/use magnetic locks for drawers/cabinets for sharps and toxins. LPA observed locked medications nearby and additional locked toxins in the laundry area. LPA observed sufficient PPE/emergency supplies. The inside temperature measured 74*F. The fire extinguisher was last serviced on 5/19/22, and facility conducts quarterly fire drills. There are (2) unlocked gates on the inside back patio and outside seating. LPA reviewed (1) of (2) resident files and (2) of (3) staff files and found them to contain current documentation, including staff training. LPA observed towels/linens on site. Discussed vaccination status of residents/staff. Hot water measured 107 *F in the kitchen. Complete First Aid Kit observed. LPA observed all required postings to be posted , including Covid posters, roster, House Rules and Admission Agreement., as well as a binder with PINS. LPA reviewed/approved Infection Control Plan previously submitted.. RCFE Admin Certificates (2) are posted. Staff are cleared and associated/requested to be associated to the facility. An updated copy of liability insurance, LIC308 and LIC500 was requested by 4/7/23. There are no deficiencies observed during today's inspection. A Technical Advisory Note is being issued. Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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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