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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701178
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:03:27 PM


Document Has Been Signed on 10/04/2023 03:03 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: 2DATE:
10/04/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:ROSA-LEAH MARTINEZ-DAVIS TIME COMPLETED:
12:00 PM
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On 10/4/23 at approximately 8:45am Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Post Licensing visit. LPA met with the administrator Rosa-Leah Martinez-Davis and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area and outside of the facility to ensure compliance with Title 22 regulations. Facility has 2 bedrooms and 2 bathrooms for resident use. Facility currently provides care for 2 non ambulatory residents.

Facility Observation: Upon entry the residents were in their rooms. Resident 1 (R1) was resting. LPA observed children’s books to aid in stroke recovery in the room. R2 was watching a BB King concert on Youtube. R2 spoke about the music and was interested in LMP’s tattoos. R2 spoke of a desire to have a tattoo in the shape of a lightening bolt on the back. R2 was alert and conversational.

During this inspection 2 resident files and 2 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements, with the exception of expired First aid and CPR training for 2 of 2 staff. Administrator will have staff complete training and email certifications. All staff noted on LIC 500 contained criminal background clearances.
Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Temperature on the heating and air unit read 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178
VISIT DATE: 10/04/2023
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 The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 7/14/23. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. The Care Tool was used during this visit.

LPA requested an updated copy of LIC 308, LIC 500, Current Liability Insurance to be emailed to Jennifer.Fain@dss.ca.gov

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Rosa-Leah Martinez-Davis.

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

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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