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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701383
Report Date: 06/12/2024
Date Signed: 06/28/2024 02:30:55 PM

Document Has Been Signed on 06/28/2024 02:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ARCADIA CARE HOMEFACILITY NUMBER:
502701383
ADMINISTRATOR/
DIRECTOR:		VILLAREAL, JOHNFACILITY TYPE:
740
ADDRESS:664 PARADISE RDTELEPHONE:
(209) 622-0295
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 15CENSUS: 12DATE:
06/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:John Villareal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 06/12/24, Licensing Program Analyst (LPA) Renee Campbell arrived announced to conduct a Pre-Licensing Visit. LPA Campbell met with John Villareal and explained the purpose of the visit. This Pre-Licensing Visit is due to a change of ownership. The facility has a fire clearance for 7 non-ambulatory and 8 bedridden residents.

A tour of the facility kitchen and food storage was conducted. Knives were observed to be locked and made inaccessible to the residents in care. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supplies to meet the resident’s needs. There is 1 smaller refrigerator for short term storage in the kitchen. In the staff office, there are 2 larger refrigerators and 1 large freezer for long term perishable storage. The facility holds enough extra non-perishable food supplies to last seven days in the same office. A monthly menu was attached to the refrigerator in the kitchen.

LPA observed a locked centralized stored medication cabinet located in the dining room. Along with the administrator, the LPA observed and reviewed the client Medication Administration Record (MAR) put in place in May of 2024. Staff are able to track if clients have accepted or refused medication and log PRN usage. The First Aid Kit was present and contained all the required components including a thermometer, scissors and tweezers.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARCADIA CARE HOME
FACILITY NUMBER: 502701383
VISIT DATE: 06/12/2024
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 A fire extinguisher was in the kitchen and hallways. They were serviced on 9/14/2023. Facility water temperature was measured at 105 degrees Fahrenheit and the thermostat was set at 80 degrees Fahrenheit.

Dining areas, living areas, and all other areas intended for resident use were toured. The dining room contained a leather couch set. Books and games were observed on shelves. Resident bedrooms contained a bed, lamp, chairs, night stands and closets. Residents were observed walking and socializing in the hallways and dining room. Dinner occurred at 4:30 pm and residents were observed receiving their medication at 3:30 pm.

The laundry room off the kitchen contained a washer and dryer and detergents that were inaccessible to residents. tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents in locked cabinets in the staff bathroom.

Pre-Licensing is complete, and this facility has no deficiencies. A Component III was completed at this time with the Applicant. Administrator Villareal had no further questions. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was conducted, and a copy of this report was given to the applicant.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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