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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700456
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:10:21 PM

Document Has Been Signed on 03/29/2023 04:10 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) 392-9814
CITY:SACRAMNETOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Patrick CainTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit on 3/29/23. LPA met with Co-Administrator Patrick Cain and explained the purpose of the visit.

Administrator holds current certification #6020161740 and expires on 9/5/2024. The facility is licensed for 6 non-ambulatory residents. Approved hospice waiver for 1. There are 5 residents present during today’s visit.

LPA inspected the physical plant including but not limited to the common area, kitchen, pantry, dining area, resident bedrooms, resident bathrooms, laundry area and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. 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 112.6 degrees Fahrenheit. Facility thermostat observed at 73 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. 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 cabinet and found medication to be locked away and inaccessible to residents. Proof of current liability insurance was observed.


Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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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: 03/29/2023
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LPA requested resident and staff files for review. LPA reviewed (5) resident files and (4) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
LIC 500 Personnel Report, LIC 610 Emergency Disaster Plan, Copy of Administrator Certificate, LIC308 Designation of Administrative Responsibility, Proof of Current Liability Insurance and resident roster.

As a result of this visit, there were no deficiencies cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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