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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002549
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:40:10 PM

Document Has Been Signed on 04/01/2022 01:40 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:AFABLE HOME CARE IIFACILITY NUMBER:
347002549
ADMINISTRATOR:AFABLE, NICOLASA O.FACILITY TYPE:
740
ADDRESS:4080 PALM AVENUETELEPHONE:
(916) 258-3737
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 4DATE:
04/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Afable NicolasaTIME COMPLETED:
01:50 PM
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Administrator, Nicolasa Afable , to follow-up on an Unusual Incident Report (IR) received by the department on 3/29/2022. Facility currently does not have any COVID-19 positive cases. LPAs wore N-95 masks while in the facility. LPAs were screened by facility staff upon entry.

IR received on 3/29/2022 stated that resident (R1) was transported to the hospital on 3/28/2022 due to an un-witnessed fall and AWOL incident from the same day . Per IR, R1 is in Mercy San Juan hospital in Sacramento and in a coma at this time.

LPAs requested medical records for R1 from facility and administrator will send all required documents to department by 04/04/22 .

At this time, this case management needs further investigation.

Exit interview was conducted with Administrator .
The signature of the Administrator on this acknowledges receipt of this document.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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