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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 12:54:28 PM


Document Has Been Signed on 08/31/2023 12:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arvin DavisTIME COMPLETED:
12:45 PM
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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 required one year annual visit. LPAs met with Licensee Arvin Davis and explained the purpose of today's visit.

The facility is a single story building with an additional building on the property for staff quarters and laundry. The facility is licensed for 4 residents and has 2 bedrooms for double occupancy. LPAs had their temperatures taken and were asked about covid symptoms on entry.

Facility had one resident in care. Resident was resting in room. During the visit Home Health arrived to see resident.

LPA Fain toured the facility including but not limited to living room, dining room, kitchen, laundry room, bedrooms and bathrooms. The facility had adequate lighting and furniture for the comfort of residents in care. The temperature in the facility was 77 degrees which falls within the required range of 68-85 degrees. The first aid kit was observed to be complete including but not limited to scissors, thermometer, tweezers, gauze, bandages and 1st aid manual. Toxins, medications and sharp objects were observed to be locked and inaccessible to residents. The kitchen was observed to be clean and sanitary. There was a 7 day supply of non-perishable food and 2 day supply of perishable food.

The fire extinguisher was last serviced on 7/14/23 and is in compliance. The resident bathroom water temperature was measured at 107.2 degrees.

Continued on 809C

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178
VISIT DATE: 08/31/2023
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Continued from 809

LPA Fain observed laundry room door propped open and pesticide and detergents accessible to residents in care.
The grounds were observed to be maintained and clear of debris with easily accessible fire escape routes.

LPA Fain requested resident’s admission agreement, 602 and needs and service plan be emailed to LPA by end of business today. Staff files will be reviewed at a future visit when the annual is completed.

Pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code deficiencies were observed and will be cited at the completion of the annual.

An exit interview was conducted and a copy of this report was provided to Arvin Davis.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
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
LIC809 (FAS) - (06/04)
Page: 2 of 2