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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700974
Report Date: 05/19/2021
Date Signed: 05/19/2021 11:15:57 AM

Document Has Been Signed on 05/19/2021 11:15 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A FAMILY AFFAIR CARE IFACILITY NUMBER:
342700974
ADMINISTRATOR:MITCHELL, KASSIAFACILITY TYPE:
740
ADDRESS:1917 ONEIL WAYTELEPHONE:
(916) 919-4590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kassia Mitchell and Patrick Cain, AdministratorsTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong arrived at this facility unannounced on 05/19/2021 at 9:40 AM to conduct a pre-licensing inspection. LPAs met with Administrator Kassia Mitchell and Patrick Cain and explained the purpose of the visit. LPA was allowed entry into the home that will be licensed for a capacity of 6 non-ambulatory residents. LPA met with Kassia Mitchell and Patrick Cain representatives of Applicant who assisted with today’s visit.

Administrator Kassia Mitchell holds current certificate # 6020161740 and expires on 9/5/2022. The LPA's toured and inspected the physical plant inside and outside with the administrator Kassia Mitchell and Patrick Cain to ensure there are no health and safety concerns on 05/19/2021 at 9:40 AM. LPA observed there are 6 residents at this time.

The facility has Covid-19 posting throughout the facility. The facility has submitted a mitigation plan to CCLD. The facility has one central entry point, and the 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.

LPAs observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPAs observed knives/sharps area to be locked. LPAs observed required furniture, and lighting throughout the facility. The hot water temperature was measured during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 70*F which is within the required range of 68-85*F.



Continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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 I
FACILITY NUMBER: 342700974
VISIT DATE: 05/19/2021
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LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPAs observed centrally stored medications area to be locked. LPAs observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home were in good repair.
LPAs observed the area where the staff and resident files are locked and readily available for review.

Component III was waived - Licensure pending. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC809 (FAS) - (06/04)
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