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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515000483
Report Date:
04/10/2024
Date Signed:
04/10/2024 04:02:47 PM
Document Has Been Signed on
04/10/2024 04:02 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ALMA AMAYA'S FAMILY HOME II
FACILITY NUMBER:
515000483
ADMINISTRATOR/
DIRECTOR:
HOUSTON, MICHAEL
FACILITY TYPE:
735
ADDRESS:
589 BIRD STREET
TELEPHONE:
(530) 671-6816
CITY:
YUBA CITY
STATE:
CA
ZIP CODE:
95991
CAPACITY:
6
CENSUS:
5
DATE:
04/10/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:
Victoria Reeder
TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility has three shared resident rooms. There is one full common bathroom and one half bathroom. This facility has a second floor in the back that has one room with is the staff area and there is a separate staff area. There is a pool in the backyard that is not in use and has a fence surrounding it. There is a locked closet for medications and a laundry area behind the kitchen. There is an ample supply of perishable and nonperishable food.
Two of five resident files were reviewed and two staff files were reviewed.
LPA did not observe any issues.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/10/2024
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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