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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 04/30/2024
Date Signed: 04/30/2024 09:13:40 AM

Document Has Been Signed on 04/30/2024 09:13 AM - 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/
DIRECTOR:		PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:831 CYPRESS AVETELEPHONE:
(707) 234-9428
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 4CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Will PraiphetsakTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a follow up visit regarding this facilities lack of Liability insurance. LPA was met with Licensee Will Praiphetsak. LPA conducted a visit on 12/26/2023 and observed Licensee did not have Liability insurance. LPA visited the facility again on 02/26/2024 to follow up on the status and learned Insurance had yet to be secured. During this visit, LPA learned Liability insurance was still lacking. LPA spoke with Licensee during this visit to provide a reminder of the importance of securing the required amounts of Liability Insurance.
During today's visit LPA observed the temperature in the home was 62.9 degrees F. LPA requested the heater be turned on to ensure the temperature is at a minimum of 68 degrees.

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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 04/30/2024 09:13 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 04/30/2024 at 08:38 AM
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
, 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2024
Section Cited

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ยง1569.605 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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reviewed, Licensee did not have Liability Insurance. This poses a potential Safety risk for persons in care.
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Type B
05/03/2024
Section Cited

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87303 Maintenance and Operation:(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on Observation, Licensee
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did not ensure facility was heated to at least 68 degree F. 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 Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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