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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804099
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:49:44 AM

Document Has Been Signed on 10/31/2024 11:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AMITY CARE HOMEFACILITY NUMBER:
486804099
ADMINISTRATOR/
DIRECTOR:		ALONZO, SHIELA MAYFACILITY TYPE:
735
ADDRESS:1876 MINI DRIVETELEPHONE:
(669) 888-6150
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 3CENSUS: 3DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sheila Alonzo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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10/31/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 clients in care. Facility approved/cleared for 3 ambulatory only. LPA was greeted by staff, Marlita Sumaoang. Administrator, Sheila Alonzo arrived shortly after. Upon arrival 2 clients were attending day program.

At approximately 10:00am, LPA and staff toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Water temperature in sinks accessible to clients in care were measured at 106.4 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last charged 05/23/2024. Outdoor area was found to be clean and fire emergency path was free of obstructions. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients in care were located in a drawer in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Cash resources were reviewed.

At approximately 10:40 am, LPA conducted a review of 3 client records. All records had the required documentation.

At approximately 11:10 am, LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.
continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMITY CARE HOME
FACILITY NUMBER: 486804099
VISIT DATE: 10/31/2024
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report
LIC308 - Designation of Responsibility
LIC400 - Client/Resident Cash Resources
Infection Control Plan - (review, update if any changes)
Emergency Disaster Plan - (review, update if any changes)

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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