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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803776
Report Date: 07/27/2021
Date Signed: 07/27/2021 11:11:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LOVING LONG LIFEFACILITY NUMBER:
216803776
ADMINISTRATOR:DE VENTURA, ANAFACILITY TYPE:
740
ADDRESS:57 VALLEJO WAYTELEPHONE:
(415) 948-9395
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Ana De VenturaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Loving Long Life for the purpose of conducting a Required-1 year inspection. LPA was greeted outside in the driveway by Administrator, Ana De Ventura. Administrator granted access into the facility.

LPA toured the facility with the Administrator, facility was found to be at a comfortable temperature with all exits free from obstruction. However, during the tour, LPA observed ants in the resident bathroom, and also observed treatment for the ants (See LIC 9102). Exits were equipped with bells. Fire Extinguisher was found to be last charged on June 2021 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. First aid kit was inspected and found to be appropriate at this time. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required and have been N95 Fit tested.

No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Ana De Ventura.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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