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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700713
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:42:06 PM


Document Has Been Signed on 01/19/2024 02:42 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 COTTONWOOD, LLCFACILITY NUMBER:
572700713
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1106 COTTONWOOD COURTTELEPHONE:
(530) 759-1234
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:8CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Paulin PantigTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1 Year Required Inspection and met with Administrator, Paulin Pantig. There were 2 staff in addition to the Administrator on site at the time of inspection. There were 5 clients in residence. The facility was very active with visitors and health care providers.

Facility was found to be clean, orderly, and at a comfortable temperature of 70-73 F with all exits free from obstruction. Water temperature measured between 111 and 115.3 F, which is within regulation. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked in cabinet between kitchen and staff room making them 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. Handwashing signs were posted in each bathroom. There was an ample supply of perishable and non-perishable foods, as required per Title 22. Infection Control Plan was submitted. Fire clearance is approved for five (5) ambulatory and three (3) non-ambulatory. Fire extinguisher was charged and dated 10/06/2023. Carbon monoxide detectors were tested and operational. Facility has fire sprinkler system which was inspected by fire department on 07/05/2023. Licensee will update license for change in LLC status.

No citations issued.

Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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