576803964-7-28-2023-21-AS-JNAA-CU6R8L-20230728124808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 07/28/2023
Date Signed: 07/28/2023 12:48:27 PM

Document Has Been Signed on 07/28/2023 12:48 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 2		FACILITY NUMBER:	576803964
ADMINISTRATOR:	DAVIS, ARVIN		FACILITY TYPE:	740
ADDRESS:	605 CONNOR LANE		TELEPHONE:	6502193369
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	8	CENSUS: 7	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Joseph Khofi		TIME COMPLETED:	12:50 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 (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. inspection of this facility. 2 care staff were present at the time of inspection. LPA had temperature taken and logged in as a visitor to the facility and access was granted. 5 residents were present at the facility and 2 residents were attending Day Program. LPA toured the facility on 7/28/2023 with staff; facility was found to be clean and at a comfortable temperature of 71 F with all exits free from obstruction. Residents' bedrooms, common areas, kitchen & food storage areas were inspected. Seven (7) smoke detectors and two (2) carbon monoxide detectors were 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 was properly stored as per regulations on this day at the time of the visit. However, LPA and Caregiver observed toxins were accessible to residents in care in a closet covered by a curtain rather than by a secured, locked door. (See LIC 809D and LIC 812-Observation/Photos). Staff did remove them immediately and placed them in a secured shed. Sharps and other items were stored inaccessible to residents in a locked drawer in kitchen. 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. Continued.....

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARVEAH'S CARE HOMES 2	FACILITY NUMBER: 576803964
	VISIT DATE: 07/28/2023

NARRATIVE

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Continued...

The following documents are requested:
LIC500
Proof of Liability Insurance
Resident Roster
Employee Roster
Signed LIC308

Infection Control Plan, Emergency Disaster Plan, Facility records, Staff records and Resident records will be reviewed at a later date and time. Staff and resident interviews will also be conducted at a later time.
Annual Continuation required.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with care staff and a copy of this report along with appeal rights .

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 12:48 PM - 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in 6 out of 6 containers of toxic substances which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that toxins are immediately removed and stored in a secured area that is inaccessible to residents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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