079200819-3-14-2025-15-AS-LHOS-DERV6E-20250314160927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200819
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:09:37 PM

Document Has Been Signed on 03/14/2025 04:09 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:	RN LOVING CARE HOME II		FACILITY NUMBER:	079200819
ADMINISTRATOR/ DIRECTOR:	LOU, JIANYIN		FACILITY TYPE:	740
ADDRESS:	921 ELM ST		TELEPHONE:	(510) 816-1173
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Yue Hui Mou and Jianyin Lou (Administrators)		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/14/25 at 08:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Yue Hui Mou and Jianyin lou Administrator (ADMs) and explained the purpose of the visit. LPA and ADMs the toured facility including, but not limited to bedrooms, bathrooms, kitchen, dining room, common area, front yard, and backyard. All outdoor and indoor passageways were free of obstruction. There were not any bodies of water observed. A comfortable temperature was maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The hot water temperature in the residents’ shared bathroom was last measured at 119.1 degrees Fahrenheit. Residents’ bathrooms were equipped with grab bars and non-skid mats. There was a minimum of one week supply of non-perishables and 2 days of perishable foods. Centrally stored medications and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition. Fire extinguisher was observed full. Emergency Disaster Plan was last posted on 04/10/24. First aid kit was observed to be complete. Safety drill was conducted 01/22/25. LPA reviewed six (6) residents records and four (4) staff records; three (3) were complete. Continued on LIC9099C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Lisha Holmes	TELEPHONE: 510-286-4201
	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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: RN LOVING CARE HOME II	FACILITY NUMBER: 079200819
	VISIT DATE: 03/14/2025

NARRATIVE

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...continued from LIC9099.

The following forms are to be updated and submitted to CCLD 03/17/25:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Pending)
-Liability Insurance (Reviewed, exp:11/2025)
-Proof of CPR

Citation issued on LIC9099D

Exit interview conducted, appeal rights, and a copy of this report provided to ADMs.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 03/14/2025 04:09 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: RN LOVING CARE HOME II	FACILITY NUMBER: 079200819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(h)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and records reviewed, the licensee did not comply with the section cited above by R1's LIC 602 ambulatory status being bedridden without fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/17/2025
	Plan of Correction
1 2 3 4	ADM to advise the local fire department, update R1's LIC602 to non-ambulatory, and/or request fire clearance if required. Self-certify that the regulation has been reviewed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Lisha Holmes	TELEPHONE: 510-286-4201
	DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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