576804240-7-15-2024-21-AS-JNAA-D77PJ8-20240715112106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576804240
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:21:19 AM

Document Has Been Signed on 07/15/2024 11:21 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:	CARE HOME AT SPANISH BAY, THE		FACILITY NUMBER:	576804240
ADMINISTRATOR:	PANTIG, PAULIN		FACILITY TYPE:	740
ADDRESS:	39374 SPANISH BAY PLACE		TELEPHONE:	(707) 592-3539
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	8	CENSUS: 6	DATE:	07/15/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robert Coleman, Licensee		TIME COMPLETED:	11:25 AM

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	LIcensing Program Analyst (LPA) Jill Nakagawa arrived for the purpose of conducting a Pre Licensing Inspection. LPA was met at the front door by Licensee, Robert Coleman, and was granted access into the facility. Fire Clearance approved for 8 nonambulatory, 2 of which may be bedridden. Paulin Pantig will be the Administrator, Administrator's Certificate # 7024304740, effective 01/07/2023 - 01/06/2025. LPA and Administrator Paulin Pantig toured the one story facility, which has 6 bedrooms, 3.5 bathrooms, and large family room and kitchen. LPA observed the facility to be clean and at a comfortable temperature of 74 degrees F with all exits free from obstruction. The fire department inspected the facility and found the Sprinkler System operational. LPA found the carbon monoxide detector to be operational during the inspection. The fire extinguisher was last charged on April 15, 2024 and was fully charged and operational. First Aid kit was inspected and found to be complete. Water temperature was 117-120 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. Medications are locked in kitchen cabinet where it is inaccessible to residents in care. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents were supplied with paper towels and hand soap, and outfitted with grab bars and non-slip floors/mats. A tour of all resident bedrooms was conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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: CARE HOME AT SPANISH BAY, THE	FACILITY NUMBER: 576804240
	VISIT DATE: 07/15/2024

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Continued from 809........

LPA discussed the Emergency Disaster Plan in detail. Licensee has a backup generator and a supply of water and non-perishables.

Component III was waived due to Licensee already being licensed.

LPA found no deficiencies at the facility at the time of inspection.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the Licensing Program Manager and assigned Application Analyst in our Department.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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