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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:57:59 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: 7DATE:
11/16/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Ken V. Hashimoto, Care StaffTIME COMPLETED:
01:56 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Arveah's Care Home 2 to perform a post licensing inspection on NOvember 16, 2021 at approximately 12:43 PM..

LPA was met at the front door where Covid-19 screening was done; a questionnaire was given and temperature taken and documented. Several residents were watching a movie in the living room, two (2) residents were taking a nap in their rooms, and another resident watching television in their room. There were 3 care staff on duty, and one care staff sleeping in staff room. Carestaff Ken Hashimoto toured LPA around the facility, which was 73 degrees. The water temperature in the kitchen was 109.4 F and one of the bathrooms was 114.6 F, which is within Title 22 acceptable regulation of 105 to 120 degrees F. The kitchen was stocked with several days of perishable foods and a week's worth of non-perishable food items. Sharps were stored and locked; inaccessible to residents. Cleaning supplies were also stored and locked; and inaccessible to residents.
Medications are kept in a locked storage cabinet in the living room, along with the First Aid Kit. There was a supply of linens and blankets for the beds.

The perimeter of the facility was surrounded by a fence, with latching gates at either entrance. The storage shed in the back yard was secured.

Each exterior-exiting door had an auditory alarm. There were two (2) fire extinguishers that were charged with a date of June 3, 2021. There were 9 operational fire alarms, and a hard-wired operational fire alarm system.

The facility has a supply of gloves, masks, face shields and gowns, as well as covered garbage cans. Signs were posted regarding Covid-19 and mask-wearing mandates.

No citations issued at this time.
Exit interview conducted with Ken V. Hashimoto, Care Staff.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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