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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804059
Report Date: 07/09/2024
Date Signed: 07/09/2024 12:12:36 PM

Document Has Been Signed on 07/09/2024 12:12 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
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:
07/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Leah Martinez-DavisTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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At approximately 09:45 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required continuation inspection of this licensed senior care facility. LPA was greeted by Administrator, Leah Davis-Martinez. 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, one resident is on hospice and bedridden. In addition, all residents have a diagnosis of dementia.

At approximately 10:00AM, LPA reviewed 6 of 6 Client records and 4 of 4 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
Resident Roster
Evidence of Liability Insurance
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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