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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000483
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:29:25 PM

Document Has Been Signed on 02/24/2022 02:29 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:ALMA AMAYA'S FAMILY HOME IIFACILITY NUMBER:
515000483
ADMINISTRATOR:AMAYA, ALMAFACILITY TYPE:
735
ADDRESS:589 BIRD STREETTELEPHONE:
(530) 671-6816
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Katherine Handrix and Vicky Reeder, care staffTIME COMPLETED:
02:30 PM
NARRATIVE
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On today's date around 11:40am, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Katherine Handrix (Staff 1, S1) and Vicky Reeder (Staff 2, S2), care staff and explained the purpose of the visit. 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. In addition, LPA was screened by staff.

LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: staff room, 2 bathrooms, 2 shared client rooms, kitchen, common area, outside area, and dining area. During the inspection, S1 informed LPA that all 6 clients are not attending day program because Client 1 (C1) was not feeling well. S1 stated that C1 is having a cough and runny nose since 2/19/2022. Around 12pm, LPA and S1 observed there to be no isolation room. LPA spoke with Licensee/Administrator Alma Amaya at approximately 12:09pm, Licensee stated that Licensee is aware that C1 has symptoms of COVID-19. Licensee stated that that the C1's has symptoms of COVID-19, but primary care doctor was not contacted for C1's changes in health condition.

LPA and Staff completed the infection control domain and citations were observed.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided. A copy of this report was left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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 2
Document Has Been Signed on 02/24/2022 02:29 PM - It Cannot Be Edited


Created By: Mai Thao On 02/24/2022 at 01:14 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ALMA AMAYA'S FAMILY HOME II
FACILITY NUMBER: 515000483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1550(c)
§1550 Licenses or administrator Certificates; suspension, revocation or denial of application; grounds The department may deny…or suspend or revoke, any license, or any special permit, certificate of approval, or administrator certificate, issued…upon any of the following grounds…or may deny a transfer of a license…for any of the following grounds: (c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observations, Licensee did not ensure to follow strictest guidelines on quarantining C1 for having symptoms of COVID-19 which poses an immediate health and safety and personal right risk to clients in care.
POC Due Date: 02/25/2022
Plan of Correction
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Staff immediately set up isolation room for C1 during the inspection. Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure to follow the strictest guidelines on isolation/quarantine at the facility by 2/25/2022.
Type A
Section Cited
CCR
85075.4(c)
85075.4 Observation of the Client (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, Licensee did not ensure that C1's physician's was contacted for having a change in health condiction which poses an immediate health and safety and personal right risks to clients in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee stated that Licensee will report C1's health condition to C1's physician. Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure when there is a change in any client's health condition, their physican is contacted by 2/25/2022.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


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