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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000625
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:01:48 PM

Document Has Been Signed on 05/16/2023 02:01 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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: 45DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amy FulkTIME COMPLETED:
02:00 PM
NARRATIVE
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On 5/16/2023 LPA Tryon visited ACE-IT-III Day Program to do an annual visit. LPA met with Program Director Amy Fulk.
LPA used the CARE Tool to do the facility evaluation.
LPA toured the facility with Ms. Fulk including classrooms, kitchens, storage rooms, quiet rooms, offices, bathrooms, hallways and outside activity area.
The program appears to be generally safe and have appropriate activity items, no hazards noted.
Fire system is checked regularly and passed the last inspection in January 2023. Fire extinguishers present and charged. LPA noted that there was no carbon monoxide detector installed as per regulation. The Director obtained a carbon monoxide detector during this visit and installed it. There is now an operational CO detector installed.
LPA reviewed 3 staff files and client information. Facility appears to have appropriate documentation completed.
Emergency Plans reviewed as well as infection control.

The following deficiency is cited as per Health and Safety Code 1502.3.
Appeal rights provided, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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Document Has Been Signed on 05/16/2023 02:01 PM - It Cannot Be Edited


Created By: Todd Tryon On 05/16/2023 at 01:09 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ACE-IT III
FACILITY NUMBER: 515000625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2


This requirement is not met as evidenced by:
Deficient Practice Statement
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Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. The program did not have a carbon monoxide detector installed.
POC Due Date: 05/17/2023
Plan of Correction
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The facility will obtain and install a carbon monoixde detector. The director purchased a carbon mooxide detector during the visit and installed it. POC cleared 5/16/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
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