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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701178
Report Date: 10/15/2026
Date Signed: 10/15/2026 02:07:32 PM

Document Has Been Signed on 10/15/2026 02:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ARVEAH'S CARE HOMES 4FACILITY NUMBER:
342701178
ADMINISTRATOR/
DIRECTOR:		MARTINEZ-DAVIS, ROSA-LEAHFACILITY TYPE:
740
ADDRESS:10620 Oak Pond LNTELEPHONE:
(650) 466-6899
CITY:Elk GroveSTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
10/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jenny LausaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 09/22/2026, Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio was told by staff that they have a resident with covid diagnosis. LPA Valerio observed staff wearing PPE.LPA Valerio contacted Administrator Rosa-Lead via cell phone. Administrator stated the first initial exposed was September 18,2026. Resident tested negative yesterday but may still be sick. On September 21, 2026, the resident was exposed again at the day program. They reported to the conservator and primary care provider. LPA received a copy of the incident report that day. LPA Valerio informed Administrator the annual inspection will be conducted at a later date.

On 10/15/2026, LPA Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with facility staff, and explained the purpose of the visit. Staff was observed assisting residents in care with ADLs. The facility consists of a main building and an adjacent structure with garage, staff quarters and laundry room. LPA Valerio inspected the main building where the residents reside. LPA Valerio observed the common areas to be fully furnished and free from debris. The living space and kitchen area were near the front entrance. LPA Valerio observed sharps, medications, and toxins to be locked an inaccessible to residents in care. LPA Valerio inspected resident bedrooms. LPA Valerio observed bedrooms to be fully furnished with clean linens, and to be free from odors of incontinence. All emergency exits were clear from obstructions. LPA Valerio observed a first aid kit, a fire extinguisher, a carbon monoxide detector, and a fire detector present in the facility. LPA Valerio observed the facility to have a two day supply of perishable food items, such as oranges, bananas, and vegetables, and a seven day supply of non-perishable food items.

Continues on LIC 809 - C...
Stephen Richardson
Christina Valerio
DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARVEAH'S CARE HOMES 4
FACILITY NUMBER: 342701178
VISIT DATE: 10/15/2026
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The exterior area was observed. LPA Valerio observed a sitting area for shaded outdoor activities, a walking pathway, and a driveway for staff cars. LPA Valerio observed no obstructions of emergency exit walk ways.

LPA Valerio observed four (4) resident files and four (4) staff files. Resident files were observed to completed with required documentation.

LPA Valerio requested the following annual documentation be sent to christina.valerio@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of liability insurance.

Per California Code of Regulations (CCR) - Title 22 - no deficiencies were cited. An exit interview was held and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC809 (FAS) - (06/04)
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