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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004164
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:26:36 PM

Document Has Been Signed on 03/11/2022 03:26 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 CARE HOMEFACILITY NUMBER:
347004164
ADMINISTRATOR:NICOLASA AFABLEFACILITY TYPE:
740
ADDRESS:4129 SINGING TREE WAYTELEPHONE:
(916) 258-3737
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
03/11/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nicolasa AfableTIME COMPLETED:
02:35 PM
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An Informal Conference was conducted at 2:00 PM on 3/11/2022 at the Sacramento North Regional Office virtually via Teams Meeting. Present for the meeting was Administrator/Licensee, Nicolasa Afable, Licensing Program Manager (LPM), Laura Munoz, LPM Anthony Perez, and LPM Troy Ordonez, Licensing Program Analyst (LPA), Talwinder Bains and the writer of this report LPA, Jacob Williams.

The purpose of the informal conference was to address the facility’s compliance issues. The Department has concerns stemming from site inspections on multiple dates during the year 2021 and 2022.

The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division for possible revocation of license.

Issues discussed during the meeting were: Record keeping, physical plant, accessible sharp objects, food service, and COVID related protocols.

To support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns.



Plan to address compliance concerns by 3/25/2022:

1. Training with all staff regarding COVID protocols and mask wearing (staff for both Afable facilities)
2. Plan to keep yards clear of all debris/wood
3. Submit grocery receipts for next 30 days (weekly from 3/11/2022 until 4/11/2022)
4. Submit meal menus for next 30 days (from 3/11/2022 until 4/11/2022)
5. Pest control receipts for cockroach infestation (last month’s receipt is sufficient)
6. Statement of understanding that all staff will follow the state’s COVID recommendations
7. Conduct staff training on how to identify expired food items

The department will provide additional facility visits and provide Administrator with RCFE Self-Assessment Guide.

No deficiencies are cited during today’s meeting.

An exit interview was conducted with Licensee Nicolasa and copy of this report was provided to her via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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