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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002549
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:03:41 PM

Document Has Been Signed on 04/01/2022 01:03 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: 4DATE:
04/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Nicolasa O Afable, AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Administrator, Nicolasa O Afable, to conduct a Plan of Correction (POC) visit. Facility currently does not have any COVID-19 positive cases. LPAs wore N-95 masks and were screened by facility upon entry. Facility staff wore masks in the care home.

Prior to visit, LPAs obtained a picture of fixed and locked drawer used to hold knives, a copy of receipts for food purchases, pictures of labeled food items, pictures of debris cleared in backyard area, and materials for PPE in-service training for staff. During today's visit, LPAs inspected food supply and observed a 2-day perishable and 7-day nonperishable food supply at the facility. LPAs also observed debris cleared from backyard.

POCs were cleared during today's visit. No additional deficiencies were issued during visit.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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