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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804241
Report Date: 07/01/2024
Date Signed: 07/01/2024 11:15:49 AM


Document Has Been Signed on 07/01/2024 11:15 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 COTTONWOOD, THEFACILITY NUMBER:
576804241
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:1106 COTTONWOOD COURTTELEPHONE:
(707) 592-3539
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:8CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Robert Coleman, LicenseeTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted a pre-licensing inspection and was greeted by Licensee Robert Coleman and Administrator-to-be Paulin Pantig. This pre-licensing inspection is being conducted due to a change of ownership. LPA will conduct Component III Orientation during today's inspection. Fire Clearance has been approved for 6 non-ambulatory residents and 2 bedridden residents. There are 6 residents in care, some of which are diagnosed with Dementia. There are 2 residents are on hospice.

LPA toured both the interior and exterior portions of the facility. Exit doors are alarmed and functional. Disaster drills are conducted regularly. The last drill covered evacuations and was conducted on May 28, 2024.
Fire extinguishers were charged and current. Smoke detectors were functional and 2 carbon monoxide detectors were present and functional. Hot water measured between 113.9 & 117.1 degrees in faucets used by residents which falls within regulation of 105 & 120 degrees F. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient supply of cleaning supplies and hygiene products available for current residents. LPA observed adequate food supply per current census. Facility was found to be a comfortable temperature of 74 degrees F. Toxins were observed stored and locked in garage. All knives and other sharp items were secured in a locked drawer in the kitchen. Required postings such as Complaint poster, Rights to resident councils, client's rights are posted in the facility. The facility contains an outdoor patio with an umbrella-covered table and chairs.
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SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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 COTTONWOOD, THE
FACILITY NUMBER: 576804241
VISIT DATE: 07/01/2024
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Resident and staff records were found to be complete. Medications are centrally stored in a locked cabinet in the dining room.

Component III Orientation completed with Licensee during today's inspection. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

This report will be forwarded to the Centralized Application Unit for continued processing.

No citations were issued during inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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