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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700712
Report Date: 03/01/2024
Date Signed: 03/01/2024 03:39:57 PM


Document Has Been Signed on 03/01/2024 03:39 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:CAREWELL AT SPANISH BAY LLCFACILITY NUMBER:
572700712
ADMINISTRATOR:PANTIG, LOURDESFACILITY TYPE:
740
ADDRESS:39374 SPANISH BAY PLTELEPHONE:
(530) 757-2027
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:8CENSUS: 6DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Paulin Pantig, Co-AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1 year required inspection and met with Co-Administrator Paulin Pantig. There were 6 residents and 2 staff present at the time of the inspection plus the Co-Administrator.

The facility was found to be clean, orderly, and at a comfortable temperature of 69-72 degrees with all exits free from obstruction. Facility has activities going on throughout the day: games, puzzles, piano, and singing. Toxins are stored in locked cabinets. Sharps are locked in cabinet in kitchen. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored in a locked cupboard in kitchen; inaccessible to residents. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were posted as required. Facility has a sufficient supply of personal protective equipment (PPE). Licensee has submitted an Infection Control Plan. There was an ample supply of perishable and non-perishable foods, as required per Title 22. Smoke alarms and carbon monoxide detectors were in place and functioning. The fire extinguisher was fully charged and last serviced on 4/18/23. The grounds were free of debris and outdoor seating was provided for warm seasonal weather. Residents were all clean, dressed appropriately, and three that were available expressed they were well taken care of and satisfied. All residents' rooms were furnished as per regulation.

No deficiencies during today's inspection. No citations issued.
Exit interview conducted with the Co-Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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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