486804059-8-24-2023-21-AS-DTOA-CUZSVF-20230824141239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804059
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:12:47 PM

Document Has Been Signed on 08/24/2023 02:12 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:	ARVEAH'S CARE HOMES 3		FACILITY NUMBER:	486804059
ADMINISTRATOR:	MARTINEZ-DAVIS, LEAH		FACILITY TYPE:	740
ADDRESS:	2033 MARSHALL ROAD		TELEPHONE:	(530) 662-6055
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 6	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Arvin Davisd		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	8/24/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Caregiver Staff, Sonia and Gener Reyes. Administrator, Leah Martinez-Davis was contacted by phone but was unable to visit. Co-Administrator, Arvin Davis arrived later in the visit. The facility is single story building licensed for 6 non-ambulatory residents, along with a hospice waiver capacity of 4. The facility currently provides care for 6 residents, none of which is receiving hospice services and some residents with a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff & Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/2/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Toxins were located in the garage and found to be secured. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 109.4 and 113.1 degrees F which is within regulation. LPA observed a medium sized hole damage in resident bedroom 1. Administrator stated that it was damaged from the previous ownership but had not initiated repairs. Administrator agrees to send photo repairs to CCLD. Technical Violation issued. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARVEAH'S CARE HOMES 3	FACILITY NUMBER: 486804059
	VISIT DATE: 08/24/2023

NARRATIVE

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Medications located in dinning area were found to be secured. Facility is utilizing an electronic Centrally Store Medication Record (CSMR). LPA conducted a spot check of medications and found several medications for residents (R1 & R5) not properly recorded on the CSMR. Administrator will be submitting plan of action to remain in compliance. Resident were observed interacting with staff in the common area watching and interacting with game shows, listening to radio or resting in their bedrooms for leisure. There are two emergency exits located in the backyard which were found to be unobstructed. All auditory alarms at the exits of the facility were found to be inactivated or in need of repair or replacement.

LPA also conducted a file review for all residents. Upon review, LPA found that residents' (R1, R2, R3 & R4) require updated Physician's Report and (R1, R3 & R4) Needs & Service Plans completed. Technical Violation issued.

Administrator Leah Davis's Administrator Certification 6055110740 is currently pending. LPA confirmed that the application renewal payment had been received as of 11/9/2022. Administrator to provide a copy of the updated Administrator Certification once received.

LPA requested the following documents be sent to CCL by COB 9/24/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership or lease/rental agreement

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2023 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARVEAH'S CARE HOMES 3	FACILITY NUMBER: 486804059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 out of 4 audtiory alarms at facility exits in need of replacing or repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Administrator agrees to replace or repair all auditory alarms located at facility exits and ensure that they are in working order. Proof of corrections form LIC9098 is to be submitted to CCLD by POC date 8/28/2023 confirming the facility is in compliance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 08/24/2023 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARVEAH'S CARE HOMES 3	FACILITY NUMBER: 486804059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above regarding several medications for residents (R1 & R2) not properly input into the Centrally Stored Medicaiton Records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit a plan of action to ensure that the facility will remian in compliance with reconsiling resident medicaiton records. In addition, Administrator to provide in-service training for all caregiver staff on medicaiton administration and recording. Plan of Action and signed proof of training to be submitted to CCLD by POC date 9/4/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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