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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 05/10/2024
Date Signed: 05/10/2024 08:51:17 AM


Document Has Been Signed on 05/10/2024 08:51 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:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:831 CYPRESS AVETELEPHONE:
(707) 234-9428
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:4CENSUS: 4DATE:
05/10/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH: Will PraiphetsakTIME COMPLETED:
09:00 AM
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At approximately 8:15AM, 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 met with Licensee Will Praiphetsak. LPA conducted a visit on 12/26/2023, 2/26/2024 and 04/30/2024 and observed Licensee did not have Liability insurance. During this visit, LPA learned Liability insurance was still lacking. LPA is issuing a civil penalty of $100 per day from 05/02 through 05/10/2024 for the failure to correct the citation issued on 04/30/2024, ยง1569.605 Liability insurance. A civil penalty of $100 per day will continue until this citation has been cleared.

This report was reviewed with Licensee and appeal rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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