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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700879
Report Date: 08/13/2025
Date Signed: 08/13/2025 05:46:12 PM

Document Has Been Signed on 08/13/2025 05:46 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, LLCFACILITY NUMBER:
392700879
ADMINISTRATOR/
DIRECTOR:		DAVIS, ARVINFACILITY TYPE:
735
ADDRESS:2502 ALEXA WAYTELEPHONE:
(650) 219-3369
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
08/13/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Paolo MallariTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis and Licensing Program Manger (LPM) Liza King arrived unannounced to conduct a quarterly visit. LPA met with the caregiver and explained the purpose of the visit.
LPM conducted a tour of the facility and observed grass and bushes overgrown on the exterior of the building blocking walk ways and emergency exits along the exterior. Additionally one of the two gates latches along the side of the house are broken and not easily accessible. An exterior exit door from a residents room to the backyard was propped closed and locked with a 2x4 jammed underneath the door handle. A seperate exit from the interior to the exterior was blocked with hoyer lifts and furniture. Spider webs and spiders located along the awnings and in some resident rooms. A tour of the interior revealed video survelillence components located in the living room which have not been approved by the Department. Mold was present in the shower.
During the previous NCC the facility agreed to:

1. Have an Administrator present 40 hrs a week - Admin was not present during todays visit according to telephone he was a dr apt with a client from another facility.
2. Have accessible an updated LIC 500 which was not accessible and was requested however changes need to be made and the licensee reported over the phone that one would be forwarded by 8/15/25.
3. Facility will have available all documents for review on demand by CCL during business hours. During todays visit all records were on the computer however limited availablity to review due to time constraints.
4. Residents records will be complaint with RCFE regulation 87506.however limited availablity to review due to time constraints
5. An LIC 308 would be followed in the event the Admin was not present - the 308 provided identifies a person however that person was not available during todays visit.

Cont.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, LLC
FACILITY NUMBER: 392700879
VISIT DATE: 08/13/2025
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6. An updated Organizational Chart and LIC 309 were submitted on 5/22/25 however a recent check of the Secretory of State shows the LLC has been suspended. According to the licensee the taxes have been paid and will be submitted by 8/15/25.
7. A repayment plan for unpaid civil penalties was provided to the Department to pay $100 a month - no payments have been made to date. According to the licensee she just started to getting paid for the clients and wants to revaluate the payment plan.

A review of records for R1 occurred incl medications MAR'S for June, July August 2025 multiple dates without signatures and or dates documented as medications unavailable. LPM spoke with caregivers- caregiver reported MAR'S were just not signed. One medication was counted and compared to the MAR, the medication was opened on 08/02/25 and is a pm medication -one extra pill was in the bottle, however multiple days were not signed.

2 residents were observed to be bedridden, interview with staff confirmed three residents currently require a hoyer lift to get out of bed. LPM observed a BS finger stick being conducted by the care giver -caregiver stated client is not able to check their BS and resident is unable to stick their belly, caregiver does it and mimic's how it would be done. The facility currently has 4 residents that receive injections. There is one client that can administer injections on their own according to staff, however usually has staff do it.. According to staff when drawing up insulin another staff has to confirm the units before the staff inject it. A review of the 602 of 2 residents states resident needs assistance with medications/ injections.

An exit interview was conducted with Paolo Mallari citations are being issued on the attached D page and Appeal rights are being provided.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2025 05:46 PM - It Cannot Be Edited


Created By: Kesha Lewis On 08/13/2025 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ARVEAH'S CARE HOMES, LLC
FACILITY NUMBER: 392700879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This was not met as evidenced by:
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Due to time constraints, Licensee will provide a Plan of Correction to Kesha.Lewis@dss.ca.gov by eod 8/14/25
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Based on a tour of the facility is was observed 2 clients whom are bedridden and several fire exits that are blocked with furniture, wood blocks or overgrown shrubs. Additionally the exterior gate(s) cannot be opened with a single action. These issues present an immediate health and safety risk to clients in care.
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Type B
08/14/2025
Section Cited
CCR87465(a)(1)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by:
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Due to time constraints, Licensee will provide a Plan of Correction to Kesha.Lewis@dss.ca.gov by eod 8/14/25
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A review of records for R1 occurred incl medications MAR'S for June, July August 2025 multiple dates without signuaters and or dates documented as medications unavailable. LPM spoke with caregivers- caregiver reported MAR'S were just not signed. One medication was counted and compared to the MAR, the medication was opened on 08/02/25 and is a pm medication -one extra pill was in the bottle, however multiple days were not signed. This is an immediate Health and safety risk to clients 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Kesha Lewis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/13/2025 05:46 PM - It Cannot Be Edited


Created By: Kesha Lewis On 08/13/2025 at 05:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ARVEAH'S CARE HOMES, LLC
FACILITY NUMBER: 392700879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
87629

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(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This was not met as evidenced by:
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Due to time constraints, Licensee will provide a Plan of Correction to Kesha.Lewis@dss.ca.gov by eod 8/14/25
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During interview and observations the facility caregiver provided injections to client without client assistance, stateing client was unable to do it themselves. This poses an immediate health and safety risk.
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Will be assessed at a later date.
Type B
08/27/2025
Section Cited
CCR87303

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by:
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Due to time constraints, Licensee will provide a Plan of Correction to Kesha.Lewis@dss.ca.gov by eod 8/14/25
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LPM observed spiders and spider webs, overgrown dead grass and bushes, mold in shower, multiple screens with holes and debris on side of house.
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Kesha Lewis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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