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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581374501
Report Date: 04/19/2024
Date Signed: 04/22/2024 10:18:42 AM

Document Has Been Signed on 04/22/2024 10:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALMA AMAYA'S FAMILY HOMEFACILITY NUMBER:
581374501
ADMINISTRATOR:HOUSTON, MICHAELFACILITY TYPE:
735
ADDRESS:1716 8TH AVENUETELEPHONE:
(530) 742-3997
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 5CENSUS: 2DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alma Amaya, LicenseeTIME COMPLETED:
04:30 PM
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On 4/19/2024 LPA Tryon visited the facility to do an annual visit. LPA met with licensee Alma Amaya.
LPA toured the home including common areas, kitchen, bedrooms, bathrooms, laundry room, office area, yard. The home is appropriately furnished and clean. Food supplies appear appropriate to meet the requirement for 2 days perishable and 7 days non-perishable. Refrigerator/freezer are at appropriate temperatures. Smoke detectors installed as well as carbon monoxide detectors. Fire extinguishers present and were just serviced.
Bedrooms are clean and appropriately furnished.
Medications are centrally stored and locked, Centrally stored medication logs are kept.
LPA reviewed 2 staff files and 1 resident file. Files include appropriate documents and information.

LPA reviewed the CARE Tool with licensee.

LPA interviewed one staff and was not able to interview residents, as residents were both out of the house at the time of the visit.

At this time it appears that the facility is in substantial compliance with the regulations. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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