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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920113
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:59:58 PM

Document Has Been Signed on 05/10/2024 12:59 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:ASA CARE HOMES INCFACILITY NUMBER:
345920113
ADMINISTRATOR/
DIRECTOR:		SANTIAGO, ANNEDREAH JOYCEFACILITY TYPE:
735
ADDRESS:7720 GUENIVERE WAYTELEPHONE:
(916) 709-4612
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 0DATE:
05/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Annedreah Santiago, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived announced for a scheduled pre-licensing inspection and met with Annedreah Santiago, Administrator. The pending license is for a level 4I home, vendorized through Alta California Regional Center, and will be for (4) clients. There are no clients currently.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) client bedrooms, (2) bathrooms, kitchen, laundry, and garage area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout and all client bedrooms were fully furnished. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. The inside temperature measured 73*F, and the hot water temperature measured 108*F in the kitchen. LPA observed sharps, toxins and medications to be locked in the kitchen and additional locked toxins in the laundry area. LPA observed sufficient towels/blankets/linens/PPE and hygiene supplies on site. Hand washing posters are near each sink and hygiene bins were set up. LPA observed smoke/monoxide alarms to be working and the fire extinguishers were last serviced 8/14/23. The fire clearance approved the facility for (3) ambulatory clients and (1) non-ambulatory client in room #4 only. LPA observed alarms on doors and there is (1) unlocked exit gate. There is a covered patio with completed landscape. LPA observed a sample resident file and staff file to be prepared, and P&I will be managed by the facility.

LPA observed the following posted: facility sketch, Personal Rights, See Something Say Something poster (will enlarge to 20" x 26"), Emergency Disaster Plan, Infection Control Plan, Adult Residential Facility Administrator # 6052700735- exp 7/2/25. Comp III was completed during today's inspection.

The following items are on order and will arrive by tomorrow, 5/11/24: fire place screen, patio chairs and table, tweezers and thermometer, (2) sets toilet grab bars, and (2) sets of shower grab bars. Administrator to provide the Department with a photo of each above item by Monday, 5/13/24.

Pre-Licensing is incomplete with deficiencies to be resolved by 5/13/24. LPA to notify CAB when documentation is received. Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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