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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002549
Report Date: 08/30/2021
Date Signed: 08/30/2021 06:00:05 PM

Document Has Been Signed on 08/30/2021 06:00 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:AFABLE HOME CARE IIFACILITY NUMBER:
347002549
ADMINISTRATOR:AFABLE, NICOLASA O.FACILITY TYPE:
740
ADDRESS:4080 PALM AVENUETELEPHONE:
(916) 258-3737
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 5DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Nicolasa Afable, AdministratorTIME COMPLETED:
06:15 PM
NARRATIVE
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On 8/30/21 Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct an annual required inspection utilizing the infection control domain. LPA met with Administrator and explained the purpose of the inspection. 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; contacted Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA toured the facility including but not limited to living room, dining room, kitchen, bathroom, and resident rooms. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days. Facility has enough 2-day perishable food and 7-day non-perishable food supply.

Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan. LPA and Administrator completed the infection control domain.


See LIC809-C for continued report
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 08/30/2021 06:00 PM - It Cannot Be Edited


Created By: Praveen Singh On 08/30/2021 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AFABLE HOME CARE II
FACILITY NUMBER: 347002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility does not document daily temperature and COVID-19 symptom checks, and/or any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility. In addition to this requirement, LPA observed S2 did not wash her hands after using the restroom.
POC Due Date: 09/07/2021
Plan of Correction
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Licensee will submit a plan for providing continuous in-service training and guidance to staff on importance of symptom screening and logging as well as proper handwashing etiquette. The plan should also include how Licensee will monitor staff to ensure this requirement is met moving forward. This plan will be sent to LPA Singh via fax or email by POC date.
Type B
Section Cited
CCR
87211(a)
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. A sign-in policy is to be enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
POC Due Date: 09/07/2021
Plan of Correction
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Licensee states a sign-in policy with appropriate symptom screening and temperature log has been implemented immediately beginning on today's date. LPA observed Licensee initiated Visitor Screening Forms during inspection. Licensee will send a statement verification of this POC to LPA Singh via fax or email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Praveen Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AFABLE HOME CARE II
FACILITY NUMBER: 347002549
VISIT DATE: 08/30/2021
NARRATIVE
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LPA observed the following violations during inspection:
  • LPA observed that facility has a sign-in policy with only names and dates of visitors, however symptom screening information is not logged.
  • Facility does not document daily temperature and COVID-19 symptom checks, and/or any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility.
  • LPA observed S2 did not wash her hands after using the restroom.
  • LPA observed cockroaches in vacant resident room, in R2's room, in hallway, bathrooms and other living space areas.

Updated copies of the following documents were requested for facility file and are to be sent to CCL by 09/7/21:

• LIC500- Personnel Report
• LIC308- Designation of Facility Responsibility
• LIC610E- Emergency/Disaster Plan
• Evidence of Liability Insurance

Deficiencies cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809-D. If the deficiency is not corrected by the noted due date civil penalties may be assessed.

Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC809 (FAS) - (06/04)
Page: 10 of 10
Document Has Been Signed on 08/30/2021 06:00 PM - It Cannot Be Edited


Created By: Praveen Singh On 08/30/2021 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AFABLE HOME CARE II
FACILITY NUMBER: 347002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(1)
(f) Solid waste shall be stored and disposed of as follows:

(1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care. LPA observed cockroaches throughout facility. Licensee stated that attempts have been made to treat the pests with over-the-counter sprays such as "Raid". However, no professional Pest Control services have been utilized. LPA observed that after incontinence care, soiled resident diapers are being openly discarded in trashcans without lids in the bathrooms.
POC Due Date: 09/07/2021
Plan of Correction
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Licensee states all solid waste will be stored and disposed of in an appropriate manner. Licensee will send verification to LPA Singh via fax or email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Praveen Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
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