<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804099
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:41:59 PM

Document Has Been Signed on 11/09/2023 04:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AMITY CARE HOMEFACILITY NUMBER:
486804099
ADMINISTRATOR:ALONZO, SHIELA MAYFACILITY TYPE:
735
ADDRESS:1876 MINI DRIVETELEPHONE:
(669) 888-6150
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 3CENSUS: 3DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marlita Sumaoang, CaregiverTIME COMPLETED:
05:00 PM
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
Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 11/09/2023 at approximately 1:50PM, and met with Marlita Sumaoang, Caregiver and Shiela May Alonzo, Administrator arrived at approximately 4:05PM. Administrator Certificate, #6060489735, is expired Administrator renewed certificate and is waiting for renewed certificate in the mail. LPA observed two caregivers working at the time of arrival. There are currently three (3) residents in care.

Facility has a required infection control plan. Facility has an emergency disaster plan as required.
All exits were free and clear of obstruction. Fire extinguisher, was last serviced on 05/12/2023 and tagged as required. LPA observed five (5) smoke alarms and 1 carbon monoxide detector, working properly during the inspection.

Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 117.1 F, which is within regulation. Medications were stored and locked making them inaccessible to residents.

There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed.



Deficiencies observed during inspection:
  • roll a way bed in the common family room

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and a copy of this report and appeals right provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/09/2023 04:41 PM - It Cannot Be Edited


Created By: Carol Fowler On 11/09/2023 at 03:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMITY CARE HOME
FACILITY NUMBER: 486804099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
POC Due Date: 11/15/2023
Plan of Correction
1
2
3
4
Administrator agreed to read and get an understanding of the regulation and conduct in-service with all staff. Administrator to provide the department with a log of the topic and attendees no later then the POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3