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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803795
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:40:30 PM


Document Has Been Signed on 09/30/2024 01:40 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CANYON VIEW SENIOR HOME CAREFACILITY NUMBER:
236803795
ADMINISTRATOR:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:512 CANYON VIEW CTTELEPHONE:
(707) 463-5589
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:7CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Will PraiphetsakTIME COMPLETED:
02:00 PM
NARRATIVE
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At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to the recent Bankruptcy notice submitted by Licensee. LPA met with Licensee Will Praiphetsak, toured the building and reviewed records. LPA spoke with Licensee about financial issues and there are no issues with this facility. Facility has sufficient food supplies. Licensee plans to issue 60 day eviction notices to the residents of the other facility with the reason being, a change of use of facility. Licensee will forward copies of the notices once they are sent. Licensee expressed interest in the opportunity to take part in the Departments Technical Support Program.

During this inspection, LPA reviewed resident files and observed 2 of 4 residents were listed as bedridden on the LIC602, Physician Report. Facility does NOT have a bedridden fire clearance. LPA provided a copy of regulation 87606, Care of Bedridden Residents and discussed with Licensee they need to submit a request to CCL for a bedridden fire clearance. LPA provided a copy of the LIC200, Application, for Licensee to complete and submit.
An immediate civil penalty in the amount of $500 is being issued for this fire clearance violation.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Will Praiphetsak and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 01:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CANYON VIEW SENIOR HOME CARE
FACILITY NUMBER: 236803795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2024
Section Cited
CCR
87202(a)

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Fire Clearance:(a)All facilities shall maintain a fire clearance approved by the city...Prior to accepting or retaining any of the following types of persons...and obtain an appropriate fire clearance.
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Licensee will submit LIC200 and a updated facility sketch to CCL to request a bedridden fire clearance. Documents shall be submitted to CCL by POC date of 10/01/2024.
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This requirement is not met as evidenced by:Based on records reviewed, facility accepted 2 of 4 residents that are bedridden. This poses an Immediate Health, Safety or Personal rights risk to persons in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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