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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 03:04:38 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/04/2023 03:04 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:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rosa-Leah Martinez-DavisTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/4/23 at approximately 12:00pm Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct a continuation of an annual inspection 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.
During this inspection 2 resident files and 2 staffing files were reviewed for regulatory compliance. Staff files contained required contents including staff training requirements. 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.

Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 7/14/23. LPA observed doors open to cleaning supplies. 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.

LPA provided Technical Assistance (TA) including, but not limited to, exceptions and waivers, change of administration, hospice and dementia care.
The facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Rosa-Leah Martinez-Davis and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.
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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Document Has Been Signed on 10/04/2023 03:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2023
Section Cited
CCR
87309

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Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Licensee will review and provide an attestation that they understand and will follow the regulation. Proof of correction will be emailed to LPA at jennifer.fain@dss.ca.gov by 10/11/23.
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Based on observation and interview, the licensee did not ensure the doors to storage rooms with cleaning supplies were locked, which poses a potential Health, Safety or, Personal Rights risk to persons 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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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