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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002902
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:39:56 PM

Document Has Been Signed on 04/05/2022 02:39 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:UNITY MEMORY HOME CAREFACILITY NUMBER:
345002902
ADMINISTRATOR:LIU, YINGFACILITY TYPE:
740
ADDRESS:8161 CHIMANGO COURTTELEPHONE:
(916) 301-8792
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 0DATE:
04/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ying (Ruby) Liu, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility on 4/05/2022 to conduct a Pre-Licensing Inspection utilizing the inspection tool. LPA met with Licensee, Ying Liu, and explained the purpose of the visit. Prior to initiating the Pre-Licensing 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 LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA toured the interior and exterior of the facility together with Licensee. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, laundry room, kitchen, and backyard. There is a staff bedroom as well. LPA observed locked cabinet in the kitchen where toxins and cleaning supplies will be located, and a separate drawer where knives/sharps will be locked. Laundry supplies will be locked in the laundry room. LPA observed the required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. Hot water temperature was measured in residents' bathrooms at 105 degrees Fahrenheit. First aid kit was completed and located in the staff room. LPA observed centrally stored medication areas to be locked in the staff room along with clients' files. LPA observed fire extinguisher in the kitchen. LPA observed fire detectors and carbon monoxide detectors.

Component III presentation conducted with Administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) analyst Katie Keith and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with Licensee. A copy of this report was provided to the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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