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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700879
Report Date: 11/04/2024
Date Signed: 11/15/2024 10:22:33 AM

Document Has Been Signed on 11/15/2024 10:22 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/
DIRECTOR:		DAVIS, ARVINFACILITY TYPE:
735
ADDRESS:2502 ALEXA WAYTELEPHONE:
(650) 219-3369
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
11/04/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:DAVIS, ARVINTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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An informal meeting was conducted today on 111/04/24 at the Sacramento Regional Office via Microsoft Teams. The purpose of this informal meeting was to discuss the deficiencies in the following areas: Acceptance regulations , care of persons with dementia, change of facility type, records and reporting requirements. Present at this meeting were Licensing Program Manager (LPM), Liza King, Licensing Program Analyst (LPA), Kesha Lewis, Designated Facility Administrator, Davis, Arvin, Leah Davis, and windy ( administrator)

LPM Liza King explained the Informal Conference process which included the Administrative Process as well.

The focus of concerns at this time were as follows:

· Facility Plan of Operation.


· Reporting requirement training
· Facility Records
. Acceptance limitations.

Count on 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARVEAH'S CARE HOMES, LLC
FACILITY NUMBER: 392700879
VISIT DATE: 11/04/2024
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The facility agreed to TSP. the department will put in a referral.
The facility also agreed to provide the RCFE plan of operation , LIC 200, facility sketch, copy of insurance and hospital admission agreement for all residents by 11/5/2024. Facility will provide the department with the in-service training plan and singed sheet for facility staff by 11/11/20024. The department will start quarterly monitoring of the facility. Facility will have a copy of the plan of operation printed and in the facility by 11/08/2024. Licensee agrees to have records for residents printed and available at the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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