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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:16:04 PM


Document Has Been Signed on 02/26/2024 02:16 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 CARE IIFACILITY NUMBER:
236803976
ADMINISTRATOR:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:831 CYPRESS AVETELEPHONE:
(707) 234-9428
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:4CENSUS: 4DATE:
02/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Will Praiphetsak TIME COMPLETED:
02:30 PM
NARRATIVE
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a plan of correction visit regarding citations issued on 12/26/2023. LPA met with Administrator Will Praiphetsak and reviewed records.
On 12/26/2023, LPA conducted a record review and found 2 of 4 residents did not have current appraisals and 3 of 4 residents did not have Physician reports that were completed in the last 12 months. During today's visit, LPA found 4 of 4 residents have current Physician reports however, 2 of 4 residents still do not have updated appraisals.
During the 12/26/2023 visit, LPA issued a citation regarding the lack of Liability insurance at this facility. LPA observed during today's visit, Licensee still does not have Liability insurance.

LPA provided copies of Regulation 87615, 87612, 87463 and 87629 for Licensee to review.

LPA discussed the Departments Technical Support Program with Licensee. Licensee is agreeable to have access to these services for assistance with Resident record documentation, Understanding of Restricted and Prohibited conditions and Hospice Care.

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 Licensee 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: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/26/2024 02:16 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 II
FACILITY NUMBER: 236803976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
HSC
1569.605

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§1569.605 Liability insurance; coverage requirements: all residential care facilities for the elderly shall maintain liability insurance... This requirement is not as evidenced by: Based on records
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Licensee to aquire Liability insurance. Evidence of Liability insurance to be submitted to CCL by POC date of 03/01/2024.
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reviewed, Licensee did not have Liability Insurance. This poses a potential Safety risk for persons in care.
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Type B
03/01/2024
Section Cited
CCR87463(c)

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87463 Reappraisals:(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any...or once every 12 months, whichever occurs first...This requirement is not met as
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Licensee to arrange a meeting with resident and their responsible parties and complete an updated appraisal. Licensee to submit Self Certification to CCL that appraisals have been updated by POC 03/01/2024.
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evidenced by: Based on records reviewed, Licensee did not not have updated appraisals for 2 of 4 residents. This poses a potential Health risk to residents 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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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