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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803861
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:39:08 PM


Document Has Been Signed on 04/25/2023 02:39 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 ATHERTON LLCFACILITY NUMBER:
486803861
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:2001 ATHERTON COURTTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 0DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Robert Coleman,
Administrator		TIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Robert Coleman. The facility currently
is undergoing a facelift and there are no residents.

LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Residents' bedrooms, common areas, kitchen & food storage areas were inspected. 2 Fire Extinguishers were found to be charged on April 25, 2023 at the time of the visit. There was one Carbon Monoxide Detector which was tested to be operational. There will a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food will be stored in the kitchen refrigerator properly as per regulations at the time of residents moving in to the facility. Toxins are stored in a locked cabinet in the facility laundry room and garage. There was a supply of cleaners, hygiene products and paper products available for clients. All clients' bedrooms will have lighting & appropriate furnishings. LPA observed medication storage for residents is a locked closet adjacent to the kitchen. Water temperature measured between 105- 120 F as per regulation, in three of the facility's faucets.

LPA inspected the backyard and found a nice deck with shade provided by umbrella; fruit trees in bloom, and accessible walkway.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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