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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:24:19 PM

Document Has Been Signed on 08/24/2023 04:24 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:BOYD, SIMEONFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: 2DATE:
08/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Sonia Jones, Caregiver , and
Boyd Simeon, Administrator via phone		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection. There was one staff member and one-on-one caregiver at the time of inspection. Administrator was contacted via phone.

LPA Nakagawa found the facility to be clean and well--organized. The 2 residents were clean and dressed appropriately, and participating in a lively conversation and sharing letters they had received with one another. Both seemed very happy and comfortable.

The bedrooms were clean and furnished as per regulation. Residents had personal items to make their rooms homey. Cameras were in use in the common areas of the facility; however the sign informing of their use was missing at the entrance to the facility. Administrator will replace.

The kitchen was clean and well-appointed with plenty of cooking equipment. The caregiver provided the residents a nice dinner at the time of inspection. The refrigerator had a good supply of perishables and there was a substantial supply of non-perishable items in the pantry.

There were no citations issued at the time of inspection.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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