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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004164
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:13:51 PM

Document Has Been Signed on 09/18/2024 03:13 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AFABLE CARE HOMEFACILITY NUMBER:
347004164
ADMINISTRATOR/
DIRECTOR:
NICOLASA AFABLEFACILITY TYPE:
740
ADDRESS:4129 SINGING TREE WAYTELEPHONE:
(916) 258-3737
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator- Nicolasa AfableTIME VISIT/
INSPECTION COMPLETED:
03:18 PM
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On 09/18/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Nicolasa Afable and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to five (5) resident bedrooms, two (2) bathrooms, kitchen, common areas, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 106.2 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 74 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in hallway, which was last inspected on 06/24/24. LPA reviewed drill logs, which are conducted quarterly. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed three (3) resident files and two (2) staff files all files contained the required documents. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents. Facility is correctly using the Medication Administration Records (MAR).

LPA requested Administrator to send updated copies of the following by 09/20/24 to LPA
  • LIC308- Designation of Administrative Responsibility
  • LIC500- Personnel Report
No deficiencies are being cited during today's inspection.
Exit interview conducted and copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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