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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700456
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:43:38 PM

Document Has Been Signed on 07/22/2021 12:43 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A FAMILY AFFAIR CARE IIFACILITY NUMBER:
342700456
ADMINISTRATOR:MITCHELL, KASSIAFACILITY TYPE:
740
ADDRESS:7526 21ST STREETTELEPHONE:
(916) 919-4590
CITY:SACRAMNETOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Patrick Cain, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 07/22/2021 at 11:20 AM to conduct an annual inspection visit. LPA met with Assistant Administrator Patrick Cain and explained the purpose of the visit.

Administrator Kassia Mitchell holds current certification #6020161740 and expires on 9/5/2022. The facility is licensed for 6 non-ambulatory residents. Approved hospice waiver for 1. There are currently 6 residents. LPA toured the facility with Assistant Administrator Patrick Cain on 07/22/2021 at 11:40 AM.

LPA inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, staff room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 115.9 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

Continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A FAMILY AFFAIR CARE II
FACILITY NUMBER: 342700456
VISIT DATE: 07/22/2021
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The facility mitigation plan was submitted to CCLD, and it was approved on 4/5/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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