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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700714
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:41:43 PM

Document Has Been Signed on 08/17/2023 04:41 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:CAREWELL AT PISTACHIO LLCFACILITY NUMBER:
572700714
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1125 PISTACHIO COURTTELEPHONE:
(530) 759-2060
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: 5DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Paulin Pantig, Administrator via phoneTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Carewell at Pistachio LLC for the purpose of conducting a Case Management- Incident inspection. LPA was granted access to the facility by carestaff. LPA spoke with Administrator via phone.

Department learned via a Special Incident Report (SIR) that on 07/16/2023 resident (R1) left the facility unassisted at 04:16 PM and was found by Local Law Enforcement nearby at 4:45 PM and returned to the facility unharmed. Resident's physician's report dated on 06/23/2022 states that resident has a diagnosis of dementia and not allowed to leave facility unassisted. Resident had been at the facility for one year with no history of wandering.

LPA discussed re-training staff regarding wandering behaviors and safe practices for caring for residents with Dementia with Administrator. Administrator agreed to conduct a review with staff.

No citations were issued.

Exit interview conducted with care staff, Sonia Jones.




SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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