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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601469
Report Date: 08/30/2024
Date Signed: 08/30/2024 06:52:53 PM


Document Has Been Signed on 08/30/2024 06:52 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: 1DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Stephanie Goldassio/Administrator TIME COMPLETED:
07:00 PM
NARRATIVE
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On this day, August 30, 2024, at 2:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Matilde Machado, licensee, and
and informed the reason for visit. Stephanie Goldassio, administrator, arrived after several minutes. LPA also met with other staff, Robert Goldassio.

Facility has Infection Control Plan that was submitted on October 5, 2022.

LPA toured the facility inside out with the licensee and later joined by administrator and other staff. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has 2 in 1 smoke and carbon monoxide detector that was tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 105 degrees Fahrenheit.

LPA reviewed 3 staff and 1 resident's files, and interviewed 1 resident. Medications inspected and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I.

LPA observed the following:
-at 5:30 pm, R1's medications filled on June 2024 and July 2024 were not recorded on LIC622.
-at 5:45 pm, facility last conducted disaster drill on April 2, 2024.

.....continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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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: 08/30/2024
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LPA received the following updated/current documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee and administrator.

Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, 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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/30/2024 06:52 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not conducting drills quartery; last drill conducted was in April 2, 2024, which poses a potential safety and/or personal rights risk to persons in care.
This is a repeat violation within 12 month period. First citation was issued on 9/27/23.
POC Due Date: 09/13/2024
Plan of Correction
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Administrator to have drill conducted and submit proof by 9/13/24.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 of R1's medications filled in June 2024 and July 2024 not recorded on LIC622 which poses a potential health and/or personal rights risks to persons in care.
This is a repeat violation within 12 month period. First citation was issued on 9/27/23.
POC Due Date: 09/13/2024
Plan of Correction
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Administrator to complete the LIC622 and submit proof by 9/13/24.
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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