576803964-7-26-2024-21-AS-JNAA-D7JTRK-20240726145740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576803964
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:57:58 PM

Document Has Been Signed on 07/26/2024 02:57 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:	(650) 219-3369
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	8	CENSUS: 7	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Leah and Arvin Davis, via phone		TIME COMPLETED:	03:05 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, which is licensed for 8, with a hospice waiver for 4. There are currently 7 residents, one of whom is on hospice care. There were 2 care staff present at the time of inspection, 4 residents were present in the facility, 2 attending day program and one at an appointment. One home health nurse was also at the facility during inspection. LPA toured the facility on 7/26/2024 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. Sharps and other items are stored inaccessible to residents in a locked drawer in kitchen. There was a supply of cleaners, hygiene products and paper products available for clients, which are locked in a drawer in supply closet, inaccessible to residents. 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 on 809-C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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: 07/26/2024

NARRATIVE

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Continued from 809...

The following documents are requested:
* LIC500
* Proof of Liability Insurance
* Up-to-date Resident Roster
* Employee Roster
* Signed LIC308
* Proof of Control of Property

Staff and Resident Records will be inspected at a later time.

There were no citations issued at this inspection.

Exit interview conducted with Caregiver Jo Ann Paragoso Goodwin.
A copy of this report was left as receipt.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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