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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 12/07/2023
Date Signed: 12/07/2023 06:43:27 PM


Document Has Been Signed on 12/07/2023 06:43 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: 5DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tootsie Sapno , Caregiver
and Paulin Pantig, House Manager
TIME COMPLETED:
06:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection. There was two staff members at the time of inspection. Administrator was contacted via phone. House Manager Paulin Panting arrived within 20 minutes.

LPA Nakagawa found the facility to be clean and well organized. The 5 residents were clean and dressed appropriately, and participating in activities and then sharing dinner and conversation.

The bedrooms were clean and furnished as per regulation. Residents had personal items to make their rooms homey. Camera was in use in resident room; sign was posted. The kitchen was clean and well-appointed with plenty of cooking equipment. There was an ample supply of perishables and non-perishables as required per regulation. The bathrooms were equipped with handsoap and paper towels. One bathroom was undergoing repairs, but the other bathrooms in the facility were operable, minimizing the impact on residents.

The facility's backyard was free of debris and had a nice outside space with tables and chairs and raised gardens for residents' enjoyment, as well as several fruit trees and a variety of plants.

LPA reviewed 5 resident files and found them to be complete. All personnel files were not available at the time of inspection, but the one reviewed was complete.
(Continued on 809-C)
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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: 12/07/2023
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LPA requested the following documentation:

LIC 308
Disaster Plan
Proof of Liability Insurance
Updated Facility Sketch
Request for Fire Inspection
Personnel files

There were no citations issued at the time of this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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