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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:33:00 PM


Document Has Been Signed on 06/07/2022 02:33 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: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: 4DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sheaena Hocog, Client Care ConciergeTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. 3 care staff were present at the time of inspection. LPA was screened for Covid-19 symptoms, vaccination records reviewed and temperature taken. Findings were documented. 4 residents were present at the facility.

LPA toured the facility on 6/7/2022 with staff; facility was found to be clean and at a comfortable temperature of 75 F with all exits free from obstruction. Residents' bedrooms, common areas, kitchen & food storage areas were inspected. Eight (8) smoke detectors and two (2) carbon monoxide detectors was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in storage room. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. All residents' bedrooms have lighting & appropriate furnishings. Medications are stored in a locked cabinet in the living room; beside that is a locked refrigerator for medications requiring refrigerated storage.

Infection Control:
Facility submitted a mitigation plan approved on 01/25/22. Posters have been placed at entrance, small table with hand sanitizer and other items designated for visitors are placed at entrance. Staff screen and do temperature checks prior to shift. Administrator was informed of the Infection Control Plan due by June 30, 2022.

Exit interview conducted with Administrator Arvin Davis via phone, and report was signed by Client Care Concierge Sheaena Hocog.

There were no deficiencies cited during this inspection.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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