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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:32:50 PM

Document Has Been Signed on 04/11/2023 04:32 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:
04/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Simeon Boyd, Licensee/AdministratorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a POST licensing inspection of this Residential Care Facility for the Elderly and met with Administrator/Licensee Simeon Boyd.
There are currently no residents; and no staff were on duty but the facility has begun interviewing staff and is prepared and ready for clients. An administrator has been lined up, but no other staff have been hired at this time.

The facility is a single story building with a capacity of 6 residents. Licensee is preparing to increase the facility to 8 once a new fire clearance is granted. LPA inspected the kitchen and common bathrooms. Bathrooms were maintained in safe and sanitary operating condition. Grab bars were present in bathrooms. Toxins are stored inaccessible to clients in care. Water temperature was within regulation of 118 to 120 degrees F. Facility will offer 3 meals a day and snacks and beverages. There were activities and music prepared for residents to enjoy.

Medications are centrally stored in kitchen area. Medication records are set up and ready for resident information and will be locked in metal cabinet. There is also a lockable medication refrigerator. Facility will not handle resident monies. The back yard and garden areas are well-tended. The back patio is awaiting delivery of outdoor furniture and an umbrella/awning.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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