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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 12/23/2021
Date Signed: 12/23/2021 01:26:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CANYON VIEW SENIOR HOME CARE IIFACILITY NUMBER:
236803976
ADMINISTRATOR:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:831 CYPRESS AVETELEPHONE:
(707) 234-9428
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:4CENSUS: 0DATE:
12/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Wirote PraiphetsakTIME COMPLETED:
01:40 PM
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of conducting a pre-licensing evaluation. LPA met with Applicant Wirote Praiphetsak and toured the facility. The facility is a 3 bedroom, 2 bathroom, single story home. Fire extinguishers were mounted and serviced within the last 12 months. Smoke detectors were tested and in working order. Carbon Monoxide detectors were present. Beds were made with appropriate linens. Resident rooms contained furniture as required. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents. A fire clearance for this facility has been granted.
Items to be addressed:
Storage area for medications
Storage area for resident and staff records
Storage area for food stores
Alert device on bedroom exit door and rear door
Building material in backyard to be removed
Lock on storage shed in back yard
Secure area for sharps in kitchen
Secure area for toxins
Additional linens and towels

Due to time constraints, the Component III orientation will be conducted at the facility during the follow up visit to verify the corrections above. Applicant will notify LPA by 01/13/2022 to schedule follow up visit.

This report was reviewed with applicant and a copy was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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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