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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 12/29/2022
Date Signed: 12/29/2022 09:25:33 AM

Document Has Been Signed on 12/29/2022 09:25 AM - 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:BOYD, SIMEONFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: 0DATE:
12/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joan D. Ellison, Licensing ConsultantTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted a follow-up pre-licensing inspection and met with Joan D. Ellison, Licensing Consultant on 12/29/22 at approximately 9:00 AM.

The following corrections were observed by LPA Nakagawa:

Required posting: CCLD complaint poster (PUB 475) in the required size 20" x 26".
Required grab bars in bathrooms by toilets.
Water temperature within regulation of 105-120 Degrees F. (temperatures in 2 bathrooms was 111 F and kitchen was 112 F at the time of inspection)
Closet door runner in Bedroom #1 was replaced.
LPA will submit the pre-licensing application report and corrections to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of the application status.

No deficiencies cited.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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