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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601577
Report Date: 10/28/2024
Date Signed: 10/28/2024 05:47:55 PM

Document Has Been Signed on 10/28/2024 05:47 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:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR/
DIRECTOR:		WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Meina Wu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 10/28/2024 at 12:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 1-year Annual Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose for the visit. LPA was greeted shortly after by Meina Wu, Administrator (ADM)

LPA requested a staff and resident roster. LPA was screened at the entry. Masks, gowns, gloves, additional sanitizer, and a visitor sign-in log is centrally stored inside the facility that is accessible to all care staff. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage and backyard. LPA observed adequate lighting and good repair of all rooms. All shared areas had covered garbage cans. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and paper towels. Hot water temperature was measured at 110.1 degree Fahrenheit (F) and the facility's temperature was 69 degree (F). Fire extinguisher was observed full and last inspected on 04/22/2024. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. Emergency disaster drill last conducted 07/2024.

The following forms are to be updated and submitted to CCLD by 11/04/2024:
-LIC500 Personnel Report & Resident Roster
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Co-Administrator Certificate

Continued on LIC809C...
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
Document Has Been Signed on 10/28/2024 05:47 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: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(6)
87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

-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 by having mattresses in the hallway, wooden boards in the backyard, black metal fencing, paint and debris from construction on the side of the house in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Licensee to provide photos to CCLD that the items have been removed by POC date.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024
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: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577
VISIT DATE: 10/28/2024
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...continued from LIC809C.

-At around 03:45 PM Mattresses in the hallway, wooden boards, black metal fencing, paint, and debris from construction on the side of the house and in the backyard.

Deficiencies observed (see LIC809D) and cited from the California Code of Regulations.

Exit interview conducted and a copy of this report provided to Meina Wu, Administrator
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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