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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:45:49 AM

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:
01/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Wirote PraiphetsakTIME COMPLETED:
12:00 PM
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At approximately 9:15AM, 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. LPA and applicant reviewed the items from the last inspection. A secure cabinet is located in the office area for medication storage. A lockable desk is available for record storage. A cabinet has been installed in the dining room to store food items. The bedroom exit door and back exit door have alert devices installed. The back yard has been cleaned of construction materials. A lock has been installed on the shed in the backyard. Locking devices have been installed on the kitchen cabinets to secure toxins and sharps. There is a supply of linens and towels for resident use. Applicant has completed all corrections requested from last visit.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

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: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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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