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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005181
Report Date: 06/10/2021
Date Signed: 07/09/2021 10:13:36 AM

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:SAC ADP DBA AIM HIGHER-ACE PROGRAM (D1-D2)FACILITY NUMBER:
347005181
ADMINISTRATOR:DAVID, MARINAFACILITY TYPE:
775
ADDRESS:4640 ORANGE GROVETELEPHONE:
(916) 993-4191
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:45CENSUS: 45DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Madonna Gonzalez, Program CoordinatorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 6/10/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Program Coordinator Madonna Gonzalez 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 and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA and staff toured facility together to ensure health and safety of clients. Areas toured include but are not limited to: courtyard, five (5) class rooms, two (2) bathrooms, kitchen, etc. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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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