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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700906
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:44:11 PM

Document Has Been Signed on 02/19/2025 12:44 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AMITY CARE HOMEFACILITY NUMBER:
342700906
ADMINISTRATOR/
DIRECTOR:
NICOLAE, MINODORAFACILITY TYPE:
740
ADDRESS:4822 IMAGE WAYTELEPHONE:
(916) 331-1136
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Administrator, Ruth Deborrah NicolaeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 02/19/25 to conduct the annual inspection. LPA met with administrator, Ruth Deborrah Nicolae and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed two residents (2) and one staff files (1). Residents files and staff files were found to be complete. LPA observed medications for 2 residents and found no errors. Facility was using Centrally Stored Log for medication management as required. Facility was clean and well organized. All required postings were observed.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher was serviced and was ready for emergency use. Hot water temperature was observed to be 111 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 72 degree F. Facility is conducting quarterly fire and disaster drill as required.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 03/10/25.
No deficiencies were observed or cited per Title 22, CCR Regulations .
Exit interview conducted. Copy of this report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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