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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:49:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/11/2023 03:49 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: 8DATE:
08/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Leah Davis via phone and
Joseph Khofi, Caregiver		TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue the Required Annual Inspection at Arveah's Care Homes 2, which was started on 07/28/2023.

LPA returned to review resident and personnel files with Co-Administrator Leah Davis. LPA reviewed three resident files and three personnel files and found them to contain the required information.

LPA did an inspection of the facility and found it to be clean and well-organized. All toxins and hazardous materials were inaccessible and locked.

All plumbing fixtures were fully functional and bathrooms had been deep-cleaned, including shower curtains.

There were no citations issued during this inspection.

Exit interview conducted with Joseph Khofi, Caregiver.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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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