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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000407
Report Date: 08/25/2023
Date Signed: 08/25/2023 12:21:03 PM


Document Has Been Signed on 08/25/2023 12:21 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: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:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Hiyasmin Samala - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection visit. LPA met administrator and explained purpose of visit.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the clients 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 measured at 109.5 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 were last inspected on 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.

LPA requested the following documents for facility file via email to CCL by August 31, 2023: LIC 308 Designation of Facility Responsibility, LIC 610-D Emergency Disaster Plan, and Liability Insurance.
ruth.wallace@dss.ca.gov

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

An exit interview was conducted with administrator. LIC 811(Confidential Names) and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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