<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 12/04/2024
Date Signed: 12/04/2024 05:48:15 PM

Document Has Been Signed on 12/04/2024 05:48 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/
DIRECTOR:
ROBERT COLEMANFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 7CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:17 PM
MET WITH:Paulin Pantig, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 3:05 PM, Licensing Program Analyst (LPA) Jill Nakagawa made an unannounced annual required inspection of this licensed senior care facility, licensed for 7 residents.

LPA met with House Manager Paulin Pantig and toured the building which was found to be clean and in good repair. LPA toured the grounds and observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were fully charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

LPA reviewed 5 of 6 resident records. All records contained current and signed admission agreements and current physician reports. Medication records are thorough and contained physician's orders for each resident. LPA reviewed 4 personnel files and found them complete, including all training and up-to-date with First Aid.

LPA requested an updated:
LIC500
LIC308
LIC610E
Proof of Insurance

No deficiencies were found at the time of inspection.

Exit interview conducted with Paulin Pantig. Copy of report left at facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2