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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002549
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:55:24 PM

Document Has Been Signed on 03/30/2023 05:55 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:AFABLE HOME CARE IIFACILITY NUMBER:
347002549
ADMINISTRATOR:AFABLE, NICOLASA O.FACILITY TYPE:
740
ADDRESS:4080 PALM AVENUETELEPHONE:
(916) 258-3868
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 5DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Jett Dulay, caregiver TIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full care inspection tool. , LPA was greeted by Jett Dulay, caregiver
and explained the purpose of the inspection. Administrator arrived at approximately 4:50 pm. LPA observed a second staff, Edward Valmonte, also present during the inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility.

The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently there is (1) resident receiving hospice services. LPA observed all residents (6) to be in their rooms resting at the start of the inspection. LPA and caregiver toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (1) resident bathroom, kitchen, staff room, laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with lids and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps in the kitchen. LPA observed locked medications nearby and locked toxins in the outside storage area. LPA observed the inside temperature to be 72*F. The fire extinguisher was last serviced on 9/16/22. LPA observed (2) unlocked gate from the inside back patio. LPA reviewed (2) of (6) resident files and found them to contain current documentation- one care plan was updated recently but is waiting for family signature. LPA reviewed (1) of (3) staff files and found staff to be cleared and associated to the facility and to have current First Aid/CPR training and the required initial training. LPA observed current copy of RCFE Administrator Certificate #6054346740- exp 11/24/23 and #6019060740- exp 9/24/24. PPE supplies are adequate..
LPA requested an updated copy of the LIC308. LIC500 and current liability insurance during today's inspection by 4/7/23. There are no deficiencies cited during today's inspection.
Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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