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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 09/24/2024
Date Signed: 09/24/2024 11:38:31 AM


Document Has Been Signed on 09/24/2024 11:38 AM - 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:ARVEAH'S CARE HOMES 2FACILITY NUMBER:
576803964
ADMINISTRATOR:DAVIS, ARVINFACILITY TYPE:
740
ADDRESS:605 CONNOR LANETELEPHONE:
(650) 219-3369
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:8CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Leah Davis, Administrator via phone and
JoAnn Paragoso-Goodwin		TIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and gather documentation regarding an incident at the facility. There were 2 care staff and 4 residents on site at the time of the inspection Two residents were attending their Day Programs.

LPA found the facility to be clean and well-organized. Care staff were busy attending the needs of the residents and preparing lunch. LPA requested resident records and staff were unable to access them on line or on site. LIcensee Leah Davis (LD) was contacted by LPA. LD reported that she has been working to transfer information via software programs but there were no records on site. A technical advisory had been issued regarding this issue on 8/13/2024, with records able to be accessed by 8/16/2024. LPA informed LD that the regulation has not been met. (See LIC 809-D).


Deficiency is cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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Document Has Been Signed on 09/24/2024 11:38 AM - It Cannot Be Edited

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: ARVEAH'S CARE HOMES 2
FACILITY NUMBER: 576803964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87506(d)

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87506 Resident Records - All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
This requirement is not met as evidenced by:
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Administrator agrees to submit self certification that all resident/staff files are accessible for review and contain all required documents by POC due date, 9/27/2024.
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Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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