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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804059
Report Date: 06/13/2024
Date Signed: 07/10/2024 09:32:18 AM

Document Has Been Signed on 07/10/2024 09:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ARVEAH'S CARE HOMES 3FACILITY NUMBER:
486804059
ADMINISTRATOR/
DIRECTOR:		MARTINEZ-DAVIS, LEAHFACILITY TYPE:
740
ADDRESS:2033 MARSHALL ROADTELEPHONE:
5306626055
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Arvan Davis-Martinez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by caregiver, Gener Reyes L. Administrator, Arvan Davis-Martinez, arrived shortly after at approximately 10:45 AM. The facility is a single story home licensed for six (6) non-ambulatory residents and a hospice waiver capacity of four (4). The facility currently provides care for 6 residents. In addition, all residents have a diagnosis of dementia.

At approximately 9:00 AM, LPA and Caregiver toured the building and grounds which was not found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected.

Signed on 07/09/2024

Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ARVEAH'S CARE HOMES 3
FACILITY NUMBER: 486804059
VISIT DATE: 06/13/2024
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Continued from 809

LPA observed food items in freezer that were not properly stored showed signs of freezer burn. LPA observed refrigerated medication not secured/lock in unclosed bin on the top shelf of the refrigerator. LPA advised Administrator to get a lock box to store medication in the refrigerator. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulation. Toxins are stored in a locked cabinet in the kitchen, and in the garage. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Water temperature measured within regulation between 116 and 117 degrees F at two of four faucets accessible to residents. Two of two fire extinguisher were onsite. Ten out of ten Smoke/Carbon monoxide detectors were present will are present. There was enough lighting in all common areas, resident rooms, and hallways.

LPA to continue Annual as facility is in the process of going digital and due to resident diagnosed with dementia demanded LPA leave the house and LPA to continue annual next week when residents are in their room to prevent further aggitation.


SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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Document Has Been Signed on 07/10/2024 09:32 AM - It Cannot Be Edited


Created By: Stefanie Mutialu On 07/09/2024 at 11:32 AM
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
, 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in rusted axe was found on a chair in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Remove all dangerous items from backyard and facility.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in medicine was found unsecured in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Secure and lock all medication including medication in the refrigerator.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


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