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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701178
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:15:03 PM


Document Has Been Signed on 10/26/2022 03:15 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ARVEAH'S CARE HOMES 4FACILITY NUMBER:
342701178
ADMINISTRATOR:MARTINEZ-DAVIS, ROSA-LEAHFACILITY TYPE:
740
ADDRESS:10620 OAK POND LANETELEPHONE:
(530) 662-6055
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rosa-Leah Martinez-DavisTIME COMPLETED:
03:21 PM
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On 10/26/22 at 9:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a pre-licensing inspection. LPA Jensen met with Licensee Rosa-Leah Martinez-Davis and explained the purpose of today's visit. The licensee will also act as the administrator and holds current administrator certificate #6055110740.

The facility will serve a maximum capacity of 4 non-ambulatory residents. The facility consists of a main building and an adjacent structure with garage, staff quarters and laundry room. The main entrance has COVID signs posted and a thermometer to screen visitors and staff. All visitors are logged in through a digital application, SmartCare. The application is installed on staff cell phones and there is an Ipad available for sign in as well. The facility has a 30 day supply of PPE available.

The main structure consists of a living room, kitchen, two bathrooms and two double occupancy bedrooms. The facility was observed to be sanitary and free of odor. The facility was also observed to be equipped with adequate lighting and furnishings for the comfort of the residents. Night lights were present in the hallways and emergency lighting was available. Activities were observed to be available for the residents.

LPA Jensen reviewed the disaster plan and found it to be in compliance. The fire extinguisher was last serviced in March of 2022 and is in compliance. The carbon monoxide and fire alarm were tested and found to be in good working order. A first aid kit was available and observed to be complete. The thermostat was set at 70 degrees and is in the required range of 68-85 degrees. The water temperature was measured in the kitchen at 105.4 degrees and is within the required regulatory range of 105-120 degrees.

The kitchen contains a locked cabinet for resident medications. There is a separate locked cabinet for cleaning supplies. Personnel files and resident files will be maintained electronically on the SmartCare application which will be accessible to licensing upon request.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178
VISIT DATE: 10/26/2022
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The laundry room is separate from the main facility and is adjacent to staff quarters. Cleaning supplies in the laundry room are locked. An adequate supply of linen was observed on hand.

The grounds were well maintained and had adequate furniture for outdoor activities. All window screens were observed to be maintained in good repair. There are no bodies of water on the property .

The facility was found to be in substantial compliance and has passed pre-licensing. A Component III presentation was completed.

An exit interview was conducted and a copy of this report was handed to the licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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