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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600855
Report Date: 07/29/2026
Date Signed: 07/29/2026 01:37:28 PM

Document Has Been Signed on 07/29/2026 01:37 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARAVILLE RESIDENTIAL CARE HOME IIFACILITY NUMBER:
415600855
ADMINISTRATOR/
DIRECTOR:		PANIZA, DORIEFACILITY TYPE:
740
ADDRESS:1136 VERMONT AVENUETELEPHONE:
(650) 799-5722
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
07/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Caregiver, Mila De VillaTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On July 29, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA met with caregiver, Mila De Villa and explained the purpose of today's visit. The administrator and the assistant administrator arrived shortly thereafter and assisted with the inspection.

A tour of the facility was conducted with caregiver. This is a single story facility with 6 bedrooms (1 staff rooms, 4 private rooms and 1 shared rooms), 2 full and 1 half bathroom/shower rooms.

Living room, dining area, kitchen and all other areas intended for resident use were observed to be furnished and able to meet the needs of the residents.

The indoor and outdoor passageways were free of obstruction. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Showers were observed equipped with non-skid mats and grab bars.

During the tour of the facility, LPA observed room 5 and the bathroom next to room had a strong urine odor. This observation was also made during the annual inspection last year.
Comfortable temperature is maintained and lighting is sufficient for comfort.

Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
April Cowan
Murial Han
DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2026
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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Document Has Been Signed on 07/29/2026 01:37 PM - It Cannot Be Edited


Created By: Murial Han On 07/29/2026 at 01:07 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1 has bed rail by the head of the bed without a physician's order. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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The Licensee will submit a plan of correction to ensure compliance and will submit a copy of the plan to CCL by 7/30/2026.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 and R3 who are not on hospice care have bed rails on the upper and lower side of their beds. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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The Licensee will submit a plan of correction to ensure compliance and will submit a copy of the plan to CCL by 7/30/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855
VISIT DATE: 07/29/2026
NARRATIVE
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Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the bathroom and kitchen was 114- 116 degrees F. Fire extinguisher were checked.

Emergency Disaster drills were reviewed to be adequate.

A review of (6) resident files was conducted and noted on the LIC 858 and during the file reviews LPA observed R1 has half bedrails without a physician's order and R2 and R3 have bedrails by the bed and the foot of their beds.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the assistant administrator, Amie Flores; A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 07/29/2026 01:37 PM - It Cannot Be Edited


Created By: Murial Han On 07/29/2026 at 01:07 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as During the facility tour, LPA observed room 2 and the bathroom next to room 2 had a very strong urine smell. This observation was shared with the administrator and the caregiver. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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The licensee will submit a plan of correction to ensure this is corrected and maintained. The licensee will submit a copy of the plan of correction to CCL by 8/7/2026.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility stated that they did not provide written notification to the local fire jurisdiction that R5 is on oxygen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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The licensee will submit a plan of correction to ensure this is corrected. The licensee will submit a copy of the plan of correction to CCL by 8/7/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/29/2026 01:37 PM - It Cannot Be Edited


Created By: Murial Han On 07/29/2026 at 01:07 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(5)
Oxygen Administration - Gas and Liquid
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above The facility did not have training records to proof that facility staff, S1 and S2 have knowledge of, and ability in operation of the oxygen/concentrator equipment.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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The licensee will submit a plan of correction to ensure facility staff have knowledge of, and ability in operation of the oxygen/concentrator equipment. The licensee will submit a copy of the plan of correction to CCL by 7/30/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


LIC809 (FAS) - (06/04)
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