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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002549
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:57:47 PM

Document Has Been Signed on 03/01/2022 02:57 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:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Nicolasa O Afable, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility unannounced on 3/1/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Administrator, Nicolasa Afable, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPAs toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 3 bathrooms for residents, 1 staff bedroom, common area, dining room, food supply, PPE supply, storage, garage, medication closet, and outdoor area. LPAs and Administrator completed the infection control domain.

Upon entry of the facility, LPAs observed that staff were not wearing face coverings while providing care to residents. During visit, LPAs observed backyard of facility contained debris, drawers containing knives were unlocked and accessible to residents in care, and food supply containing a large amount of expired food items, unlabeled and undated food items, and open food packages.

As a result of today's inspection, deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80072(a)(2) regarding staff wearing face coverings while inside the facility, Section 87555(b)(8) regarding food supply, Section 87705 (f)(1) regarding accessible knives, and Section 87303(a) regarding debris in backyard. Deficiencies are listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/01/2022 02:57 PM - It Cannot Be Edited


Created By: Michael Hood On 03/01/2022 at 12:02 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2022
Section Cited

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidence by:
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During inspection conducted by CCLD on 3/1/2022, LPAs observed staff not wearing face masks while inside the facility, which poses an potential health, safety, and personal rights risk to the residents in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


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Document Has Been Signed on 03/01/2022 02:57 PM - It Cannot Be Edited


Created By: Michael Hood On 03/01/2022 at 02:12 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: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During visit, LPAs observed food supply with multiple expired items, open packages, and food items without date or label. Based on observations, the facility did not ensure residents had a sufficient supply of food, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Facility will replenish food supply and ensure food items are labeled and dated. Facility will submit receipts for food and pictures with labeled food by POC due date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations during visit, the facility did not ensure that knives were locked and inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Facility will fix drawer used to lock knives and submit pictures showing corrections to CCLD by POC due 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/01/2022 02:57 PM - It Cannot Be Edited


Created By: Michael Hood On 03/01/2022 at 02:12 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: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During visit, LPAs observed debris in backyard. Based on observations, the facility did not ensure that backyard was clear of debris, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2022
Plan of Correction
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Facility will clear debris in backyard and submit pictures of cleaned backyard to CCLD by POC due 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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