576803964-7-27-2021-21-AS-KWAS-C5BTN9-20210727145223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 07/27/2021
Date Signed: 07/27/2021 02:52:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	ARVEAH'S CARE HOMES 2		FACILITY NUMBER:	576803964
ADMINISTRATOR:	DAVIS, ARVIN		FACILITY TYPE:	740
ADDRESS:	605 CONNOR LANE		TELEPHONE:	(650) 219-3369
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	8	CENSUS: 6	DATE:	07/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Applicant, Arvin Davis		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) K. Walters and J. Nakagawa arrived unannounced and met with applicant, Arvin Davis for the purpose of conducting a Pre-Licensing inspection. Facility is currently licensed and new facility will be a Change of Ownership. LPAs conducted a risk assessment with Applicant, Arvin Davis, who will be the Administrator once the license is approved. Upon entry, LPA's were screened for COVID-19 symptoms, which was then logged into facility I PAD. Alcohol based sanitizer was available. LPA observed a 30 day supply of Personal Protective Equipment. (PPE) The facility has designated indoor/outdoor visitation areas. The applicant has a mitigation plan for COVID-19, which has been submitted to Community Care Licensing. LPAs toured the facility with AD at 10:00 AM. LPAs observed that auditory alarms were not present in three bedrooms and that the auditory alarm was turned off in the living room. LPAs observed that carbon monoxide alarms and smoke detectors were operational. The fire extinguisher was last inspected on 06/03/2021. Woodland Fire Department granted the facility a clearance on 7/7/2021 for 8 non-ambulatory residents. The facility is one story with 6 bedrooms, 3 bathrooms, office room, staff room, and a fenced back yard. The outside grounds were free of any apparent hazards, and fire exits were clear. No accessible bodies of water. No firearms. The interior living room, dining room and kitchen were adequately furnished. Continued 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ARVEAH'S CARE HOMES 2	FACILITY NUMBER: 576803964
	VISIT DATE: 07/27/2021

NARRATIVE

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Continued from 809

LPAs observed locked cabinets for resident and staff records observed in the office. Medications were locked in the office cabinet. Kitchen was spacious and clean, adequate supply of dishes and utensils. Refrigerators were clean, with perishable and non-perishable foods. Kitchen cabinets and several shelves were supplied with can/dry goods, paper products and emergency water. LPAs observed sharps in unlocked kitchen drawers. Sharps were accessible to residents with dementia. (pictures taken). Applicant immediately removed and locked all sharps. Bathrooms were supplied with slip mats. Bedrooms were observed to be clean with adequate dressers and closet space for belongings. Hot water temperature measured at 136.2, 136.7 and 142.3, which is not within requirements of 105 to 120 degrees. The Component III Orientation was completed during today's visit.

A subsequent Pre-Licensing inspection is needed to ensure the following items are corrected and reviewed:

· Applicant will ensure water temperature measures between 105-120 degrees.
· Applicant will ensure all sharps are locked and inaccessible to individuals with dementia.
· Applicant will ensure that all smoke detectors are operable and alarms are on.
· Applicant will install auditory alarms on all doors leading to exterior.
· All required postings will be posted. (Let us know, Resident Rights, and Theft and loss)
· B3's closet door will be repaired by 8/3/21.(pictures taken)
· Obtain prescription for all residents 1/2 bed rails.

This pre-licensing is incomplete. The above items are to be resolved by 08/03/21. A follow up Pre-licensure LIC809 will be generated upon resolution of listed items above. LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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