197610274-9-9-2024-31-AS-ERIS-D8XQVS-20240909123049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610274
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:30:58 PM

Document Has Been Signed on 09/09/2024 12:30 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
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:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Mark Belmonte		TIME COMPLETED:	12:45 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 total capacity of 6 with fire clearance for five (5) non-ambulatory residents, and one (1) bedridden. At approximately 9:50 a.m. LPA and administrator tour the physical plant of the facility and the following was observed: Bedrooms: There are six (6) total bedrooms one of which is for staff use only. Five (5) bedrooms are designated for resident use one (1) of which may be shared. Bedroom are currently private. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed various hallway closets and cabinets used as storage for extra facility supplies. In one (1) of the supply closets LPA observed a fully supplied first aid kit. Auditory alarms were observed on Exit doors and were functioning properly. Bathrooms: There are three (3) bathrooms. One (1) bathroom is located in a bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured at 10:15 a.m. and read between 117 and 118.5 degrees Fahrenheit within regulation. 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. LPA observed fresh fruit and sealed snacks located at the kitchen counter and on a side table in the common area for residents. Knives and sharps were stored in a locked kitchen drawer. LPA observed cleaning supplies locked under the kitchen sink cabinet. (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: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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
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: 09/09/2024

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 sit the capacity of the facility. Seating such as couches and arm chairs where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. During visit LPA observed residents playing cards and scrabble. LPA observed two (2) telephones accessible to residents.

Laundry and Garage: 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 the laundry room. LPA observed a freezer and a refrigerator in the garage with extra food.

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 bodies of water on property.

There are dual carbon monoxide and smoke detectors that are hard wired and interconnected. Administrator tested detectors at 10:20 a.m. and LPA observed detectors properly functioning. LPA observed sprinklers and a fire door. There are two fire extinguishers both observed fully charged with purchase date 07/12/24.

Resident and Staff Files: At 10:50 a.m. LPA reviewed resident and staff files. Files are maintained locked in the staff room. LPA conducted a file review of five (5) out of five (5) resident records to insure compliance of licensing forms. LPA also conducted a file review of three (3) staff records to insure forms and training are up to date and in compliance with licensing forms.

Medications: At 12:02 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a 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: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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