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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 12/13/2022
Date Signed: 12/13/2022 02:36:30 PM

Document Has Been Signed on 12/13/2022 02:36 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:BOYD, SIMEONFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 6CENSUS: 0DATE:
12/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Simeon Boyd, LicenseeTIME COMPLETED:
02:45 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
Licensing Program Analyst (LPA) Jill Nakagawa conducted an initial pre-licensing inspection and met with Simeon Boyd, the Licensee. The facility has a fire clearance approval from the Davis Fire Department of 5 nonambulatory, and 1 bedridden, for a total capacity of 6 residents. The facility has a Dementia Care Plan within their Plan of Operation. Facility will operate with hourly staff and Licensee will ensure sufficient staffing at all times.


During today’s visit LPA observed the following items:
· COVID-19 screening station with visitor log.
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed.
· 10 hardwired smoke detectors, which were tested and observed operational.
· 2 carbon monoxide detectors, tested and observed operational.
· Complete First Aid kit, night-lights, and flashlights for emergency lighting.
· Supply of paper products available.
· Fire Extinguisher charged.


Component III orientation was completed with the applicant during this inspection.

(cont'd on 809-C)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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
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: ELDERLY CARE ON CALMIA
FACILITY NUMBER: 576804111
VISIT DATE: 12/13/2022
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
26
27
28
29
30
31
32
 Pre-licensing is incomplete with corrections needed

The following corrections are needed to proceed with the application process:



Required posting: CCLD complaint poster (PUB 475) in the required size 20" x 26".
Required grab bars in bathrooms by toilets.
Decrease Water temperature within regulation of 105-120 Degrees F.
Closet door runner in Bedroom #1 needs to be replaced.

Applicant to provide pictures of the corrected items as proof of correction to LPA Nakagawa. Once LPA receives the corrections, LPA will submit the pre-licensing application report and corrections to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of the application status.

No deficiencies cited.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2