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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:36:00 PM

Document Has Been Signed on 12/19/2023 04:36 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:ELDERLY CARE ON CALMIAFACILITY NUMBER:
576804111
ADMINISTRATOR:ROBERT COLEMANFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Paualin Pantig, House Manager and Robert Coleman, Administrator via phoneTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Elderly Care on Calmia on 12/19/2023 for the purpose of addressing a deficiency. LPA met with staff member.

During recent inspection on 12/07/2023 LPA toured the facility and observed changes in the facility's layout due to the addition of a wall in kitchen area; which added an additional bedroom to the facility. A new facility sketch was not submitted to the Department, and an inspection by the Fire Department was not requested as per regulation. (See LIC 809D and Civil Penalty).

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed in the amount of $500.00 (See LIC 421M dated for December 19, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the and appeal rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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: ELDERLY CARE ON CALMIA
FACILITY NUMBER: 576804111
VISIT DATE: 12/19/2023
NARRATIVE
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**An immediate civil penalty in the amount of $500 was assessed today for the fire clearance violation.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Provided.

LPA is requesting the submission of the following:

LIC200
Updated facility sketch
Request for Fire Department Inspection

Exit interview conducted with Paulin Pantig, House Manager, whose signature on this document
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2023 04:36 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 12/19/2023 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ELDERLY CARE ON CALMIA
FACILITY NUMBER: 576804111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.This requiement was not met as evidenced by:

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Licensee to submit required documents needed (formal request, LIC 200, update facility sketch) to request a fire clearance inspection for facility's changes. . Licensee to submit a statement that they understand the regulation and shall be in future compliance. POC due date12/20/2023 to CCL.
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facility's floor plan and operations. This presents an immediate health, safety and personal rights risk to the residents in care.
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*** An immediate Civil Penalty in the amount of $500 was assessed.

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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
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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