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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002549
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:37:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2022 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220502151128
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:
05/19/2022
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Nicolasa Afable, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility fails to address the infestation of bed bugs
INVESTIGATION FINDINGS:
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On May 19, 2022, Licensing Program Analyst,(LPA) DeAnna Williams-Lyons arrived unannounced to
deliver findings for complaint # 25-AS-20220502151128. LPA met with administrator, Nicolasa, Afable, and explained the reason for the visit.

Prior to the visit, 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 licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

The licensee did advised LPA that there were bed bugs in the facility. The licensee stated she had Clark Pest Control come to the facility to treat the bed bugs. The licensee said that the pest control company has recently been to the facility a minimum of 3 times to spray bed area and carpets.
To continue see 9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 25-AS-20220502151128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2022
NARRATIVE
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During this investigation LPA DeAnna Williams-Lyons did the following to resolve allegation: Received invoices from Clark Pest Control of all the treatments conducted in the last 3 months. Also received confirmation of payment of the treatment being completed by Clark Pest Control. For the foreseeable future Clark Pest Control will be performing monthly maintenance for the next 2 months.

Based on LPA's observations and interviews which were conducted and recorded, the preponderance of evidence standards has been met, therefore, the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, copy of report given.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20220502151128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. The licensee did not ensure that the facility was safe from pests and rodents.
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The licensee has agreed to submit a report on how she will ensure that the facility is safe from pests and rodents. Licensee will submit all invoices from the pest control company POC due date is 6/19/2022.
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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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3