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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 08/10/2021
Date Signed: 08/10/2021 03:49:37 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 2FACILITY NUMBER:
576803964
ADMINISTRATOR:DAVIS, ARVINFACILITY TYPE:
740
ADDRESS:605 CONNOR LANETELEPHONE:
(650) 219-3369
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:8CENSUS: 6DATE:
08/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Arvin Davis, Applicant/AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa performed an unannounced subsequent visit on 08/10/2021 to assure that Applicant Arvin Davis has resolved all Pre-Licensing deficiencies:

~Water temperature was tested at 111.3 degrees F. Applicant understands the water temperature shall be within 105-120 degrees F.
~Applicant has provided a locking drawer in the kitchen for sharps to ensure all sharps are locked and inaccessible to individuals with dementia.
~Applicant has demonstrated to LPA that all smoke detectors are operable.
~LPA observed that auditory alarms are on all doors leading to exterior.
~ LPA observed salmon-colored bedroom closet doors are properly secured.
~Required postings were observed.
~Applicant received physician’s orders for all residents using ½ bed rails.

Component III was completed with applicant Arvin Davis on 7/27/2021.

Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.

LPA will submit pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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