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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200827
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:30:15 PM

Document Has Been Signed on 01/14/2025 04:30 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 HANDS CARE HOME LLCFACILITY NUMBER:
079200827
ADMINISTRATOR/
DIRECTOR:		SAN DIEGO-TOMAS, CECILIAFACILITY TYPE:
740
ADDRESS:748 VAQUEROS AVETELEPHONE:
(510) 245-3738
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 3DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Edelyn Tupas, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 1/14/2025 at 12:00pm, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual required inspection. LPA met with Caregiver, Edelyn Tupas, and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 135 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary. Hand washing poster and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher were not tagged. Fire drill last conducted 12/09/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 6
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 HANDS CARE HOME LLC
FACILITY NUMBER: 079200827
VISIT DATE: 01/14/2025
NARRATIVE
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Continued from LIC809.

Three (3) staff records were reviewed, one was complete and two (2) were incomplete. All three (3) clients' records were reviewed and 1 was complete and 2 incomplete.

Deficiencies observed by LPA during record review:
  • At 1:04PM LPA observed shower faucet was leaking.
  • At 1:09PM LPA observed the water temperature is 135 degrees F.
  • At 1:29PM LPA observed screen door and screen on side yard window is tore.
  • At 1:35PM LPA observed Administrator Certificate is expired.
  • At 1:40PM LPA observed Fire Extinguisher has no tag or receipt taped to cylinder.
  • At 1:55PM LPA observed Staff and Resident files are not complete.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

The following forms to be updated and submitted to CCLD by 1/30/2024:
  • LIC610D Emergency disaster plan (last page)
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • Administrator current Certificate.



Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to staff..
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/14/2025 04:30 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/14/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOVING HANDS CARE HOME LLC
FACILITY NUMBER: 079200827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having water temperature at 135 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
1
2
3
4
Administrator agreed to turn down the water heater and submit a video to the Department showing the water temperature by the POC date.
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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/14/2025 04:30 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/14/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOVING HANDS CARE HOME LLC
FACILITY NUMBER: 079200827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a leaking faucet located in bathroom #1 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Administrator agreed to have a plumber repair or replace the faucet in the shower and submit a picture of the receipt and the faucet once repaired/replaced to the Department by the POC date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the screen door leading to the backyard tapped and a window screen on the left side of the house in disrepair which poses a potential health and safety or risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Administrator agreed to have the screen door and window screens replaced and submit photos to the Department by the POC date.
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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/14/2025 04:30 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/14/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOVING HANDS CARE HOME LLC
FACILITY NUMBER: 079200827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation. the licensee did not comply with the section cited above by having an expired Administrator Certification which poses a potential health and safety risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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2
3
4
Administrator agreed to provide a copy of a current Administrator Certificate to the Department by the POC date.
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not having complete Administrator and staff files which poses a potential health and safety risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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2
3
4
Administrator agreed to read the regulation and update all staff files and submit a sample copy to the Department by the POC date.
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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/14/2025 04:30 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/14/2025 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOVING HANDS CARE HOME LLC
FACILITY NUMBER: 079200827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having fire extinguishers without tags or purchase receipt taped on the cylinder to show date of purchase or when last inspected which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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2
3
4
Administrator agreed to tape the purchase receipt on the cylinder and provide a copy to the Department or have the fire extinguishers replaced and tagged. by the POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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