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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700879
Report Date: 09/12/2025
Date Signed: 09/30/2025 09:27:01 PM

Document Has Been Signed on 09/30/2025 09:27 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:
09/12/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Arvin Davis TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities continued substantiated noncompliance since the last NCC conducted on 05/05/25 . Present at today’s NCC were Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Stephen Richardson , Licensing Program Analysts (LPA) Kesha Lewis, Sommer Hayes Wendy Martinez Assist. Administrator and Licensee Arvin Davis Leah Davis. The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.

Citations from licensure to 05/05/25 - six (6) A type citations in areas of Inspection Authority (repeated) , Basic services and Client Records, Acceptance and Retention Limitations and Reporting Requirements. One (1) B type citations in the past 3 years in the area of Administrator - Qualifications and Duties.

Citations since NCC Meeting on 05/05/25 include 6 additional Type A citations in the areas of Acceptance and Retention, Incidental Medical and Dental and Fire Safety. Additional Type B citations in the areas of Buildings and Grounds and Incidental Medical and Dental
Issues discussed related to the above include:
Ongoing issues with:

1. Inspection Authority -A plan to ensure Resident and staff records resident records will be available for review at the facility.- the process of reviewing records is timely
2. Plans of Correction submitted timely – ongoing issue
3. Acceptance/Retention and Compatibility (related to IDDM individuals 602 states cannot administer, staff interview and observations is staff are testing blood sugar and administering insulin)
5. Personal Rights
6. Presence of Administrator – since the NCC the Administrator has not been present upon arrival. Additionally, the Administrator reports staffing shortages which cause him to provide care during the overnight shift. Several discussions including on the prior NCC that his role as a caregiver needs to be separate from his role as an Administrator which is responsible for the day to day oversight of the facility.
7. Unpaid Civil penalties totaling $20,100 – Agreement reached on 09/10/25 for repayment of $2,010 per month for 10 months. Additional CPs issued on or after 09/10/25 shall be paid within 30 days of invoicing.
8. Update on RCFE application
NEW FTB Suspension – proof was provided that taxes were paid for the prior years. 2024 remains unpaid proof of payment will be sent to the department by 9/19/2025.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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: 09/12/2025
NARRATIVE
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Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:
1. Administrator present 40 hrs a week
2. Provide an updated LIC 500 for all facilities and a designated presence of the Administrator 40 hours a week at Arveah's care homes LLC.
3. Facility will have available all documents for review on demand by CCL during business hours.
4. Residents records will be complaint with RCFE regulation 87506
5. A repayment plan for unpaid civil penalties beginning 10/01/2025
6. Restricted Health Conditions - Exceptions request for 4 residents will be submitted by 9/19/2025
7. Fire Clearance CCLD will notify the local fire department of the bedridden residents at the facility, additionally a quote for doors to be installed in the facility to gain bedridden clearance will be sent to the department by 9/19/2025
8. facility will email all documentation to to the sacro email given during the meeting.

Citations were issued for Administrator Qualifications during todays meeting and appeal rights were provided. An exit interview was conducted via telephone and a copy of this report was sent electronically for signature.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 09:27 PM - It Cannot Be Edited


Created By: Kesha Lewis On 09/12/2025 at 01:29 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: 09/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2025
Section Cited
CCR
87405(d)(1)

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87405 Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
(d) The administrator shall have the qualifications specified in Sections
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Licensee will review regulation and submit a statment of understanding to the department by 9/15/2025.
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This requirement is not met as evidenced by: Based on observation and interview with with the licensee. Information was not known regaring the title 22 regulations. This poses a potential health,and saftey risk to 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Kesha Lewis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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