342700974-5-30-2023-27-AS-TTRG-CSBQNV-20230530121946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700974
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:19:54 PM

Document Has Been Signed on 05/30/2023 12:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	A FAMILY AFFAIR CARE I		FACILITY NUMBER:	342700974
ADMINISTRATOR:	MITCHELL, KASSIA		FACILITY TYPE:	740
ADDRESS:	1917 ONEIL WAY		TELEPHONE:	(916) 421-0467
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 5	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Kassia Mitchell		TIME COMPLETED:	12:30 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 5/30/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Administrator Kassia Mitchell and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator holds current certification #6020161740 and expires on 9/5/2024. The facility is licensed for 6 non-ambulatory residents. Hospice waiver approved for 1. There were 2 residents present during today’s visit. LPA inspected the physical plant including but not limited to the common area, kitchen, pantry, dining area, resident bedrooms, resident bathrooms, laundry area and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 105 degrees Fahrenheit. Facility thermostat observed at 71 degrees Fahrenheit. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication cabinet and found medication to be locked. Proof of current liability insurance was observed. LPA requested resident and staff files for review. LPA reviewed (5) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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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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: A FAMILY AFFAIR CARE I	FACILITY NUMBER: 342700974
	VISIT DATE: 05/30/2023

NARRATIVE

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Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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