079200827-1-5-2024-15-AS-CFOR-CZ7TAZ-20240105133423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200827
Report Date: 01/05/2024
Date Signed: 01/05/2024 01:34:36 PM

Document Has Been Signed on 01/05/2024 01:34 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 LLC		FACILITY NUMBER:	079200827
ADMINISTRATOR:	SAN DIEGO-TOMAS, CECILIA		FACILITY TYPE:	740
ADDRESS:	748 VAQUEROS AVE		TELEPHONE:	(510) 245-3738
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 5	DATE:	01/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Princess Nido, Caregiver		TIME COMPLETED:	02:14 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 1/05/2024 at 9:30am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Princess Nido, Caregiver, and explained the purpose of the visit. Cecilia San Diego-Tomas, Administrator arrived at 10:45am. The Administrator currently holds a certificate (#6048434740) that expires on 06/28/2024. The facility’s fire clearance was approved for four (4) non-ambulatory and four (4) bedridden residents. LPA toured the facility with Caregiver Princess Nido including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms, and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 74.8 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. New Fire extinguisher will be purchased on 01/06/2024. Emergency Disaster Plan was last posted on 1/15/2023. First aid kit was observed to be complete. LPA reviewed five (5) resident files and three (3) staff files which were found to be incomplete. Administrator had electronic copies of documents and will update resident and staff files. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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 HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
	VISIT DATE: 01/05/2024

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

· At 10:21am, LPA observed 2 ladders, buckets, bedframes, concrete mix, paint, shovels, wood pallets, wood boards with nails, hoyer lyft, large umbrella frame located in the backyard.

LPA requested the following documents to be submitted to CCLD by 1/12/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report along with appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/05/2024 01:34 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 HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(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 2 ladders, buckets, bedframes, concrete mix, paint, shovel, wood pallets, wood boards with nails, hoyer lyft, large umbrella frame located in the backyard, which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/22/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have 2 ladders, buckets, bedframes, concrete mix, paint, shovel, wood pallets, wood boards with nails, hoyer lyft, large umbrella frame removed from the backyard and email photos to CCLD 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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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