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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700714
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:08:05 PM


Document Has Been Signed on 02/23/2024 04:08 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 PISTACHIO LLCFACILITY NUMBER:
572700714
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1125 PISTACHIO COURTTELEPHONE:
(530) 759-2060
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 6DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Kirk Lisondra, Caregiver and Paulin Pantig, Administrator (via phone)TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1 year required inspection and met with Kirk Lisondra, Caregiver and Paulin Pantig, Administrator (via phone). There were 6 residents in care at the time of inspection, clean, well-groomed and dressed appropriately. There was one caregiver on duty.

Facility was found to be clean, orderly, and at a comfortable temperature of 73F with all exits free from obstruction. Toxins are stored in locked cabinets and in the locked laundry room. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored in locked cabinets in the kitchen making them inaccessible to residents. Sharps were also locked and 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 up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). There is an approved Fire Clearance and hospice waiver for six (6) residents. Water temperature measured approximately 107 F in 2 out of 2 faucets, which is within regulation. The carbon monoxide detector was tested and found to be operational. Fire extinguisher was fully charged and last serviced on May 3, 2023. There was an adequate supply of perishable and non-perishable foods. Residents' rooms were furnished as required, clean and well-organized. There was an ample supply of linens.

Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREWELL AT PISTACHIO LLC
FACILITY NUMBER: 572700714
VISIT DATE: 02/23/2024
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LPA requested the following documents:

Proof of liability insurance
Updated Resident Roster
Staff Roster
LIC 500
Documentation of Fire Drills/Emergency Drills
Staff Trainings

LPA will return to complete Annual Inspection: LIC 859

No citations issued during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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