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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804059
Report Date: 07/28/2022
Date Signed: 07/29/2022 01:16:30 PM

Document Has Been Signed on 07/29/2022 01:16 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 3FACILITY NUMBER:
486804059
ADMINISTRATOR:MARTINEZ-DAVIS, LEAHFACILITY TYPE:
740
ADDRESS:2033 MARSHALL ROADTELEPHONE:
(530) 662-6055
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 5DATE:
07/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Leah Martinez-DavisTIME COMPLETED:
02:43 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted an announced pre-licensing inspection on 07/28/2022. LPA met with Applicant, Leah Martinez-Davis who will be the Administrator once the facility is approved for licensure. The applicant submitted an application to change ownership to the centralized application unit. The facility is currently licensed as Davis Senior Living, 486803816. Once the change of ownership is approved, the facility will be licensed as Arveah's Care Home 3. The facility has a fire clearance approval from the Vacaville City Fire Department for a total capacity of 6 Non-Ambulatory residents (the facility does not have approval for bedridden). Facility will operate with 24/7 staffing (staff room available) and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
  • COVID-19 postings and screening station; LPA was screened upon arrival.
  • Lockable separate cabinets for medications, toxins/cleaners, and knives.
  • All exits were unobstructed; 1 Fire Extinguisher charged and serviced 03/24/2022
  • Smoke detectors and 1 carbon monoxide detector, which were tested and observed operational
  • Complete first aid kit, night-lights leading to bathroom, and flashlight for emergency lighting
  • Supply of linens, paper products, and hygiene supplies available
  • Required furnishings in all resident bedrooms
  • Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Ombudsman poster).
  • The water temperature was tested during inspection and was within regulation of 105 - 120 Degrees F
  • Medication was pre-filled for 3 days, in a 7 day pill container.
  • LPA learned that staff (S1) was not associated to Davis Senior Living.
Report continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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: 07/28/2022
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Continued from 809

During the visit It was identified that a terminally ill bedridden resident is residing in the facility. Resident (R1) is considered bedridden based on their physician report. Facility does not have bedridden clearance from the fire department. The Regional Office is working with the facility to notify the fire department of R1's change in bedridden status. LPA is requesting that the applicant provides evidence that they have notified the fire department that this individual is still in the facility after the 14 day and will need an extension of the temporarily bedridden status to allow for a terminally ill hospice resident. In addition, the facility will ensure that they update their emergency disaster plan should a resident who is now bedridden more than 14 days need to remain in care. Along with ensuring they follow the parameters of the document attached. The facility will provide a plan to make necessary modifications in order to request approved permanent bedridden fire clearance for the facility moving forward in the future.

Deficiencies observed will be cited under Davis Senior Living facility

The Component III Orientation was completed; Pre-licensing is complete. LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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