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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701178
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:08:21 PM


Document Has Been Signed on 08/31/2023 01:08 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: 1DATE:
08/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arvin DavisTIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/31/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management visit related to acceptance and retention limitations. LPAs Jensen and Fain met with Co-Administrator Arvin Davis and explained the purpose of today's visit.

On July 14, 2023 the facility submitted an exception request to accept a resident with a gastronomy tube, a prohibited health condition. The Department reviewed the documentation submitted and determined that the resident in fact had multiple prohibited conditions and expressed those concerns to the Licensee. Based on an interview with co-administrator Arvin Davis, the resident was admitted on 7/30/23 despite not having received an approval from the Department. LPAs requested the resident file for review and observed that under section 8, the care home has "a sound monitoring device in the home to monitor residents during times that staff may be outside of the home or in separate laundry room."

Furthermore, during the course of the visit LPAs Jensen and Fain observed a staff member on duty who, according to Arvin Davis is not associated to the facility.

Technical assistance was provided on prohibited health conditions. Deficiencies are being cited from the California Code of Regulations (CCR). Civil Penalties are also being assessed.

An exit interview was conducted and a copy of this report, an LIC 811, and appeal rights were given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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 4


Document Has Been Signed on 08/31/2023 01:08 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87615

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Prohibited Health Conditions
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
(2) Gastrostomy tubes.
(3) Naso-gastric tubes.
(4) Staphylococcus aureus ("staph") infection or other serious infection.
(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement was not as evidenced by:

(6) Tracheostomies.
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The Licensee agrees to submit a plan to come in to compliance within 24 hours and will email the plan to maja.jensen@dss.ca.gov for review and approval.
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Based on LPA Fains observation of R1 and a file review for R1 and the Co-Administrators own admission that a resident with prohibited health conditions was accepted. This poses an immediate risk to the health, safety and personal rights of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/31/2023 01:08 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
80072(a)(1)

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Personal Rights
...each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other person. This requirement was not met as evidenced by:
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The Licensee agrees to immediately remove audio recording equipment from the interior of the facility and to revise the admission agreements and submit the revision to maja.jensen@dss.ca.gov by 9/7/23.
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Based on a review of the admission agreement for R1, section 8 states the facility uses audio monitoring when staff are not present in the facility. This poses a potential risk to the health, safety and personal rights of residents in care.
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Type B
09/29/2023
Section Cited
CCR87405(d)(2)

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Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...
Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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The Licensee agrees that the Administrator and the co-administrator will complete an additional 4 hours of training specific to regulations relating to Residential Care Facilities for the Elderly and will submit proof of completion to maja.jensen@dss.ca.gov by POC due date.
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Based on the facility accepting a resident with a prohibited health condition without an exception by the Department. This poses a potential risk to the health, safety and personal rights of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/31/2023 01:08 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87411(g)(2)

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Personnel Requirements - General
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:...
Request a transfer of a criminal record clearance as specified in Section 87355(c)
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The Licensee agrees to have all staff associated by POC due date.
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Based on Co-Administrator Arvin Davis' own admission that the staff present during the course of the visit was not associated to the facility. This poses an immediate risk to the health, safety and personal rights of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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