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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601469
Report Date: 09/21/2022
Date Signed: 09/21/2022 07:34:47 PM


Document Has Been Signed on 09/21/2022 07:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:LOVING HOME CAREFACILITY NUMBER:
015601469
ADMINISTRATOR:GOLDASSIO, STEPHANIEFACILITY TYPE:
740
ADDRESS:22270 PERALTA STREETTELEPHONE:
(510) 582-8839
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:5CENSUS: 2DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Matilde Miguel Machado/Licensee and
Robert Goldassio/Operations Manager		TIME COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Matilde Miguel Machado (licensee), Robert Goldassio (operations manager), and Stephanie Goldassio, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan on file. Operations manager stated that they are working with a vendor to add the Monkeypox Infection Prevention to the facility's new Infection Control Plan.

LPA toured the facility inside out with the licensee and operations manager. LPA inspected the living room, dining area, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked and observed adequate for 30 days, and antigen test kits are readily available. COVID-19 signages were observed throughout the facility. Trash bins were observed with foot pedal operated lids. Bathroom lavatories were observed with liquid soap and paper towels in dispensers. LPA verified, and operations manager stated that the staff were fit tested for N95 March 2021 and have not been re-fit tested.

Fire extinguishers checked and observed fully charge with tags showed serviced September 1, 2022. Hot water temperature in the common bathroom was tested and measured at 105 degrees Fahrenheit.

....continued next page
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LOVING HOME CARE
FACILITY NUMBER: 015601469
VISIT DATE: 09/21/2022
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LPA observed resident's (R1) medication unlocked in the refrigerator.

Licensee to submit the following by October 5. 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Facility's new Infection Control Plan
6. N95 fit testing records/certificates

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the licensee, administrator and operations manager.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/21/2022 07:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LOVING HOME CARE
FACILITY NUMBER: 015601469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(C)
87465 Incidental Medical and Dental Care
(h)(1)(C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above. LPA observed resident's medications unlocked in the refrigerator which poses an immediate health risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Staff removed the medications immediately.
Licensee to purchase a locked box and in-service the staff, Picture and copy of in-service training with attendees signatures to be submitted by 09/22/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3