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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804059
Report Date: 09/30/2022
Date Signed: 09/30/2022 12:40:21 PM

Document Has Been Signed on 09/30/2022 12:40 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: 4DATE:
09/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Arvin DavisTIME COMPLETED:
12:54 PM
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On 9/30/22 LPA Walters arrived at this facility unannounced and was greeted by Licensee, Arvin Davis (AD) for the purpose of conducting a complaint investigation. During the course of the visit, LPA observed areas of non-compliance unrelated to the complaint.

When touring the facility with AD LPA observed that a bottle of hygiene products in resident R1's bedroom. LPA reviewed R1's physician report and learned that R1 had a dementia diagnosis. LPA explained to AD that toxins should be stored in a lock container or in an area where residents who have dementia are unable to access it.

LPA requested to review resident records and learned that all records were stored online. The Licensee needed to create a web access code for LPA to review records. Some records were available to reviewed online, and others were locked in a cabinet in the facility. Licensee stated that they didn't have access to those records. LPA explained that all records need to be in the facility and available upon demand as required per regulation.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/30/2022 12:40 PM - It Cannot Be Edited


Created By: Katrina Walters On 09/30/2022 at 12:02 PM
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: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2022
Section Cited
CCR
87705(f)(2)

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(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:
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Licensee to remove all items that pose a danger to persons with dementia from residents bedrooms. Licensee to self certify that all toxins have been removed and send proof to LPA Walters by POC due date.
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Based on observation, the licensee did not comply with the section cited above in 1 of 4 residents, who had a bottle of hygiene product in their bedroom. which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/03/2022
Section Cited
CCR87506 (a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Licensee will develop a plan to be able to access resident records for all residents and ensure they are easiely accessed. Licensee to send proof by POC due date 10/03/22
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Based on observation, record review and interview, LIcensee did not comply with this regulation. Licnesee was unable to furnish resident records for R2
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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