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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000625
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:31:22 PM

Document Has Been Signed on 04/14/2022 12:31 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:ACE-IT IIIFACILITY NUMBER:
515000625
ADMINISTRATOR:AMY FULKFACILITY TYPE:
775
ADDRESS:1670 SIERRA AVE, SUITE 601TELEPHONE:
(530) 673-4585
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 60CENSUS: 0DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Amy Fulk, AdministratorTIME COMPLETED:
12:30 PM
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On 4/14/2022 around 11:30am, 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 administrator Amy Fulk 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA and Administrator toured the facility together to ensure health and safety of residents in care. During today's inspection, there are 0 clients currently attending the Day Program on-site. Administrator stated that the facility is currently providing virtual services to clients only. Areas toured include but are not limited to: common areas, activity rooms, medication room, two (2) bathrooms, kitchen, storage areas, and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

During today's inspection, LPA and Administrator discussed mitigation protocols but not limited to, isolation room, isolation PPE cart, screening procedures and documentation, and importance of mask wearing. LPA did not conduct an overview of P&I cash resources and medications for clients due to COVID-19, no client are currently attending program on-site.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report was left at the facility with Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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