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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803858
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:01:53 PM


Document Has Been Signed on 04/28/2023 03:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CAREWELL AT PEACOCK, LLCFACILITY NUMBER:
486803858
ADMINISTRATOR:COLEMAN, MARIEFACILITY TYPE:
740
ADDRESS:475 PEACOCK WAYTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:6CENSUS: DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ron-Mark Adriano, Program ManagerTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Required – 1 Year Annual Inspection for this facility and met with Ron-Mark Adriano, program manager. The facility currently provides care for five (5) residents, one (1) of which is on hospice and two (2) of which have a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Residents' bedrooms were all equipped with the required furnishings, lighting and linens. Common areas were comfortably furnished, kitchen & food storage areas were inspected. The Fire Extinguisher was found to be charged on 04/14/2023 at the time of the visit. There were (2) carbon monoxide detectors that were tested to be operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Knives and sharps were locked kitchen cabinet. Toxins are stored in a locked cabinet in a designated storage room and garage. There was a supply of hygiene products and paper products available for residents. Medications were stored and locked inaccessible to residents. The facility has a backyard surrounded by grape vines, with seating available to residents wanting outside time.

The Licensee has submitted a Mitigation Program Plan and Infection Control Plan which have been approved. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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