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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804111
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:25:39 PM

Document Has Been Signed on 07/13/2023 04:25 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: 2DATE:
07/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tootsie Sapno , Caregiver
and Paulin Pantig, House Manager via phone		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and case management visit regarding incidents of resident R1, on 5/17/23, 5/27/23, 6/29/23. There were 2 residents at the time of visit, and 2 staff on site.

LPA observed the following: facility was clean, well-organized, and a comfortable temperature. Residents were clean and dressed appropriately, and socially engaged with staff and one another. LPA did not observe any behavioral issues.

Interviews were conducted with residents and staff.
LPA requested the following documents for R1: most recent physician report, current care plan.

No citations are being issued today.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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