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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 04:28:37 PM

Document Has Been Signed on 12/19/2023 04:28 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:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Paulin Panting, House Mgr. and Robert Coleman, Administrator (via phone)TIME COMPLETED:
04:35 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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