455002885-2-22-2022-25-AS-RKNT-CBVQ8D-20220222105633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455002885
Report Date: 02/22/2022
Date Signed: 02/22/2022 10:58:43 AM

Document Has Been Signed on 02/22/2022 10:58 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	ACTING WITH LOVE ASSISTED LIVING		FACILITY NUMBER:	455002885
ADMINISTRATOR:	SANCHEZ, ANTHONY		FACILITY TYPE:	740
ADDRESS:	2635 SAPPHIRE LANE		TELEPHONE:	(530) 941-1473
CITY:	ANDERSON	STATE: CA	ZIP CODE:	96007
CAPACITY:	8	CENSUS: 0	DATE:	02/22/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tasha Tompkins - Licensee		TIME COMPLETED:	11:30 AM

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	02/22/2022 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct a Pre-Licensing visit for a re-location application. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves. LPA met with licensee Tasha Tompkins and explained the purpose of the visit. Comp 3 was waived by licensee as they are currently licensed for 2 other facilities. Licensee plans to close the two existing facilities and relocate all residents into the one new facility. The fire marshal has approved the fire safety inspection request. The facility is licensed for a total capacity of 8 residents, 3 of which may be non-ambulatory residents. The inside of the facility was observed to be in good condition and repair. The facility has four (4) bedrooms, four (4) bathrooms, two (2) kitchens, two (2) dining areas, two (2) living rooms, one (1) laundry room, one (1) medication room, and 2 garages. There is currently no furniture located in one living room, and both dinning area. One living room has a couch and love seat. When the licensee closes their two other facilities they will bring the furniture from the other facilities to furnish the new facility. Continued on LIC809-C

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING	FACILITY NUMBER: 455002885
	VISIT DATE: 02/22/2022

NARRATIVE

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Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwashers, stoves, microwaves and refrigerators were all present and working.

The facility has four fully charged fire extinguishers which were inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. There is a whole house sprinkler system which is hard wired to the local fire department.

Two bedrooms were observed to have beds in them. The other two bedrooms will be furnished when the other two facilities close. Each bedroom has ample storage. The facility has 2 linen closets which contains sheets, pillowcases, towels and face cloths. Bathrooms were observed to be in good repair. The bathrooms are set up with paper towels and soap for hand washing.

The facility has a medication room, a lock will be placed on the door to the medication room. Medications are to be stored in this room in a locking cabinet. Facility files will also be stored in this room.

Storage and lighting are adequate in the home. Cleaning supplies and toxins are to be locked up in a cabinet in the laundry room. Also locked in the kitchen are knives. Washer and dryer observed in place and ready for use in laundry room.

The back yard has two nice shaded structures. The licensee will move the outdoor furniture from the two facilities that are closing for residents to use.

LPA reminded licensee that they need to prepare the facility for Covid-19 restrictions before they can move residents into the facility.

The applicants have passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

No deficiencies according to CCR Title 22, Division 6. Exit Interview and copy of report was emailed to the licensee.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC809 (FAS) - (06/04)

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