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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700879
Report Date: 10/09/2024
Date Signed: 10/10/2024 08:19:39 AM


Document Has Been Signed on 10/10/2024 08:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 3DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Wenddenberg Martinez TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and administrator joined 40 minutes later. LPA explained the purpose of the visit to Administrator and staff.

Due to time issues and needed documentation LPA will return at a later date to complete the annual inspection.

Citations were issued. See 809D page.

Exit interview. copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/10/2024 08:19 AM - 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, LLC
FACILITY NUMBER: 392700879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85070

85070 Client Records

(a) In addition to Section 80070, each client record must contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the three out of three records reviewed. All Resident records were not available upon request. which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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A plan to ensure resident records will be available is to be sent to LPA Lewis by COB on POC date.
Type A
Section Cited
CCR
85068.4(g)

Acceptance and Retention Limitations. The licensee shall not accept or retain the following:

g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above all residents at this facility 3 out of 3 are all over the age of 60 years old which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will submit for a change is license type or serve an eviction notice to being them into compliance.
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: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/10/2024 08:19 AM - 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, LLC
FACILITY NUMBER: 392700879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80022(a)

Plan of Operation (A) Each licensee shall have and manintain on file a current, written, definitive plan of oppenation.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above based on LPA asked to review plan of operation and it could not be provided. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will submit the plan of operation to LPA by COB on POC date.
Type A
Section Cited
CCR
85061

Reporting Requirements
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of three counts. The licensee had not insormed the department residents were in care. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will create a plan to ensure reporting to the department is done on time.
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: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3