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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002885
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:35:32 PM

Document Has Been Signed on 02/06/2025 12:35 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:ACTING WITH LOVE ASSISTED LIVINGFACILITY NUMBER:
455002885
ADMINISTRATOR/
DIRECTOR:		TOMPKINS, TASHAFACILITY TYPE:
740
ADDRESS:2635 SAPPHIRE LANETELEPHONE:
(530) 941-1473
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY: 12CENSUS: 10DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Tasha Tompkins AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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02/06/2025 at 9:45 AM Licensing Program Analyst (LPA) Sarah Benson and Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA's met with administrator Tasha Tompkins (cert # 7013177740 exp.2-1-25) and explained the purpose of the visit. Administrator certificate is current.

LPA's and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to five (5) resident rooms, common areas, four (4) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.


The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.
The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 9-11-24, the facility has not been conducting drills every 3 months.

LPA interviewed one of one resident and one staff.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.


Exit interview conducted and copy of report was provided to administrator
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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Document Has Been Signed on 02/06/2025 12:35 PM - It Cannot Be Edited


Created By: Sarah Benson On 02/06/2025 at 12:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff had expired first aid and two out of three staff did not have TB test in file out of which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Obtain heath screen and email LPA Benson when complete.
Complete first aid training and email LPA Benson when complete.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in the last fire drill was conducted on 9-11-24 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Will have emergency drill.
Will email LPA Benson when compled.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/06/2025 12:35 PM - It Cannot Be Edited


Created By: Sarah Benson On 02/06/2025 at 12:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one out of ten residents in care had no smoking-oxygen in use sign posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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 post No smoking-Oxygen in Use sign.
was completed during LPA visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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