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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700879
Report Date: 11/07/2022
Date Signed: 11/07/2022 11:46:40 AM


Document Has Been Signed on 11/07/2022 11:46 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ARVEAH'S CARE HOMES, LLCFACILITY NUMBER:
392700879
ADMINISTRATOR:DAVIS, ARVINFACILITY TYPE:
735
ADDRESS:2502 ALEXA WAYTELEPHONE:
(650) 219-3369
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 0DATE:
11/07/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Arvin DavisTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPA's) Kesha Lewis and Albert Johnson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Administrator Arvin Davis. LPA'S were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator. Administrator's Certificate # 6048451740 10/13/2023.

LPA's and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 0. At this time the facility has not been vendored by VMRC. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care. LPA's also conducted the infection control domain tool.

Hot water temperature was measured at 100 F degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees Fahrenheit. LPA's observed the following posted on the facility wall: Facility license, sketch.

The facility has not submitted a LIC 808 mitigation plan, to be approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ARVEAH'S CARE HOMES, LLC
FACILITY NUMBER: 392700879
VISIT DATE: 11/07/2022
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LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have no food at the time of this visit due to there being no residents in the facility at this time.

LPA's observed, fire extinguishers inspected on 11/8/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

Currently there is not staff at the Facility.

LPA Lewis requested updated copies via email to LPA by November 11th, of Infection control plan including Monkey pox. Kesha.Lewis@dss.ca.gov



Exit interview held with staff and copies of reports left at conclusion of visit
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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