197610274-11-7-2023-31-AS-ERIS-CXCU5M-20231107141659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610274
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:17:08 PM

Document Has Been Signed on 11/07/2023 02:17 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOREVER LOVE HOME CARE INC.		FACILITY NUMBER:	197610274
ADMINISTRATOR:	BELMONTE, MARK		FACILITY TYPE:	740
ADDRESS:	44920 LOTUS LN.		TELEPHONE:	(661) 206-7518
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mark Belmont		TIME COMPLETED:	02:16 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	Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit for this facility. LPA met with the administrator, Mark Belmont and administrator designee Mylene Veatch and explained the reason for the visit. The facility is licensed for a capacity of 6 with fire clearance for five (5) non-ambulatory residents, and one (1) bedridden. At approximately 10:10 a.m. LPA and administrator tour the physical plant of the facility and the following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. Knives were stored in a locked kitchen drawer. Bedrooms: There are six (6) total bedrooms one of which is for staff use only. Five (5) bedrooms are designated for resident use and are currently private. Bedrooms were observed to be properly furnished with appropriate bedding and sufficient lighting. LPA observed two (2) hallway closets used as storage for extra linens, toiletries, and incontinent care. There are dual carbon monoxide and smoke detectors that are hard wired interconnected. Administrator tested a detector at 10:07 a.m. and LPA observed detectors properly functioning. LPA observed sprinklers and a fire door. There are two fire extinguishers both observed fully charged. One fire extinguisher is located at the kitchen, and the other is in the garage. Bathrooms: There are three (3) bathrooms. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and hand rails. Hot water temperature was measured at 10:14 a.m. and read 118.5 degrees Fahrenheit within regulation. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOREVER LOVE HOME CARE INC.	FACILITY NUMBER: 197610274
	VISIT DATE: 11/07/2023

NARRATIVE

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Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to seat up to six residents. The auditory alarms on all exit doors were on and functional at the time of the visit. Fireplace was off and secured with a screen.

Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is no swimming pool or bodies of water on property. The laundry room is located in the hallway by the residents' rooms and leads to the attached garage. Laundry room was observed locked. Detergents and cleaning supplies were observed locked in a bathroom cabinet. LPA observed a freezer and a refrigerator in the garage with extra food.

Resident and Staff Files: Resident and staff files are maintained locked in the staff room. LPA conducted a file review of resident records to insure compliance of licensing forms. LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms.

Medications: Medication and Medication Records are stored in a locked cabinet in the kitchen. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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