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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000407
Report Date: 08/15/2022
Date Signed: 08/15/2022 11:42:06 AM


Document Has Been Signed on 08/15/2022 11:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CYON SAMALA FAMILY CARE HOME #2FACILITY NUMBER:
347000407
ADMINISTRATOR:SAMALA, ASUNCION CJ.FACILITY TYPE:
740
ADDRESS:1547 BELL STREETTELEPHONE:
(916) 929-9699
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:H.C SamalaTIME COMPLETED:
11:50 AM
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On August 15, 2021 at 10:32am Licensing Program Analyst (LPA) Chris Hopkins arrived at Cyon Samala Family Care Home #2 for the purpose of conducting an unannounced required 1 year annual inspection. A risk assessment call was performed prior to entry verifying there were no active covid cases. LPA met with Administrator, H.C Samala and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.
LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing signs and COVID-19 informational signs posted throughout the facility. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Liability Insurance.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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