415601161-10-14-2025-14-AS-JCAA-DMFTRR-20251014145757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601161
Report Date: 10/14/2025
Date Signed: 10/14/2025 02:58:04 PM

Document Has Been Signed on 10/14/2025 02:58 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:	ARK, THE		FACILITY NUMBER:	415601161
ADMINISTRATOR/ DIRECTOR:	APANDE, CAROL		FACILITY TYPE:	740
ADDRESS:	1320 VALOTA RD		TELEPHONE:	(650) 995-7552
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY: 6		CENSUS: 6	DATE:	10/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Evelyn Wilcox, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE

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On October 14, 2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Evelyn Wilcox, Caretaker and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms and 4 and a half bathrooms, a living room, kitchen and backyard. No accessible bodies of water or hazards were observed. All bedrooms had the required furniture and sufficient lighting. Hot water temperature was measured between the required 105-120 degrees Fahrenheit. All bathrooms had the required grab bars and anti-skid floor mats. The facility had the required 2 days of perishables and 7 days of non-perishables.

All soap, poisons, and detergents were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 5 staff files and 5 resident files. All were observed to be complete.

During the inspection, LPA Calandra observed that the knives drawer in the kitchen was unlocked and accessible to persons in care. A Type A citation was provided for this deficiency.

LPA Calandra also observed on a previous visit on 10/7/2025 that the Licensee locks the exterior gate in front of the facility and takes care of residents who have been diagnosed with Dementia. LPA confirmed that facility staff lock the exterior gate. A Type A citation was provided for this deficiency.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

The Annual will be completed at a later date.

An exit interview was conducted. This report was reviewed with facility representative and a copy along with Appeal Rights provided.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

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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Document Has Been Signed on 10/14/2025 02:58 PM - It Cannot Be Edited

Created By: John Calandra On 10/14/2025 at 02:27 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: ARK, THE	FACILITY NUMBER: 415601161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not have sharp objects(knives) locked and in-accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2025
	Plan of Correction
1 2 3 4	Licensee shall ensure that all sharp objects are locked and in-accessible to persons in care and provide proof of correction(POC) to the Department by the POC due date.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the licensee did not ensure that fire clearance includes approval of locked perimeter fence gate, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2025
	Plan of Correction
1 2 3 4	Licensee will remove the lock and send proof of correction to the Department by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:

	John Calandra
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC809 (FAS) - (06/04)

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