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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581374501
Report Date: 04/07/2022
Date Signed: 04/07/2022 10:17:24 AM

Document Has Been Signed on 04/07/2022 10:17 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ALMA AMAYA'S FAMILY HOMEFACILITY NUMBER:
581374501
ADMINISTRATOR:AMAYA, ALMAFACILITY TYPE:
735
ADDRESS:1716 8TH AVENUETELEPHONE:
(530) 742-3997
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 5CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Alma Amaya, LicenseeTIME COMPLETED:
10:25 AM
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On today's date around 8:00am 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 Alma Amaya, Licensee. LPA 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, Staff screened LPA prior to entering the facility.

LPA toured facility with Licensee to ensure health and safety of clients in care. Areas toured include but are not limited to: common area, 1 client bathroom, 2 shared client bedrooms, 2 staff bedrooms, 1 client room, laundry room, garage, kitchen, and storage areas. LPA and Licensee completed the infection control domain with Licensee. During the inspection, there was only Licensee present with 3 clients. 3 clients were still sleeping, 1 client is currently out staying with family.

At approximately 8:23am, LPA and Licensee toured the kitchen and dining area. LPA and Licensee observed some dirty dishes in the sink. LPA discussed the incident with Licensee. Licensee stated that the dirty dishes were from breakfast. Licensee cleaned the dishes and put it away during the inspection. At approximately 8:29am, LPA and Licensee toured the laundry room. LPA and Licensee observed that the laundry room leads to another room. LPA and Licensee was not able to get through to the other room because there were clutters blocking the way . LPA discussed what was observed with the Licensee. Licensee stated that the items belong to Licensee's family member.

(continue 809-C......)
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
FACILITY NUMBER: 581374501
VISIT DATE: 04/07/2022
NARRATIVE
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At approximately 8:34am, LPA and Licensee observed some small buckets stacked on top one another in the client bathroom. In one of the bucket, there was some dirty rags in them. LPA and Licensee discussed what was observed and Licensee stated that it was from cleaning last night. Licensee immediately removed the rags and bucket. At approximately 8:36am, Licensee and LPA observed a second staff room, unlocked, filled with clutters as well. Licensee stated that the "garbage" are left behind to Licensee from Licensee's mother. At approximately 8:44am, LPA and Licensee did a walk through around the outside premises. LPA and Licensee observed a door leading into the garage. LPA was not able to enter the garage due to clutters filled with tools and many other items blocking entry. LPA discussed what was observed with Licensee.

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 were provided to Licensee. A copy of this report was left at the facility with Licensee, whose signature on this document confirms receipt.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 10:17 AM - It Cannot Be Edited


Created By: Mai Thao On 04/07/2022 at 09:23 AM
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
FACILITY NUMBER: 581374501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above in 1 out of 1 client restroom and 1 out of 1 kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Licensee immediately cleaned the dishes and removed the rags and buckets from the bathroom during the inspection. Licensee agrees to submit in statement to Licening stating how Licensee can ensure the kitchen and bathroom stays cleaned for clients, employees, and vistors.
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:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 10:17 AM - It Cannot Be Edited


Created By: Mai Thao On 04/07/2022 at 09:37 AM
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
FACILITY NUMBER: 581374501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above laundry room, storage areas, and staff room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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LPA and Licensee disccused POC, Licensee stated that Licensee will removed clutters from laundry room, staff room, and storage areas by 5/9/2022.
Section Cited
Deficient Practice Statement
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4
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:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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