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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200819
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:13:35 AM

Document Has Been Signed on 04/28/2022 11:13 AM - 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:RN LOVING CARE HOME IIFACILITY NUMBER:
079200819
ADMINISTRATOR:LOU, JIANYINFACILITY TYPE:
740
ADDRESS:921 ELM STTELEPHONE:
(510) 816-1173
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Administrator, Yue 'Andy' M0uTIME COMPLETED:
11:13 AM
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On 04/28/2022 at 09:31 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by one staff upon entry and explained the purpose of the visit with the Administrator, Yue 'Andy' Mou (ADM).

Facility has a COVID-19 mitigation on file. LPA obtained a resident and staff roster, and discussed staffing schedules with ADM. LPA observed screening station at the entry that contained a thermometer, hand sanitizer, masks, COVID signage and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing signs posted in the common areas. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods. All hand washing stations were equipped with soap and paper towels. Hot water temperature in the shared residents' bathroom was measured at 116.8 degrees Fahrenheit. Fire extinguisher was last serviced on 02/19/2022. Smoke/Carbon Monoxide detectors are combined and observed operational.

The following forms are to be updated and submitted to CCLD by 05/05/2022:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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