216803776-6-23-2022-21-AS-FSAI-CFNMYU-20220623100206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803776
Report Date: 06/23/2022
Date Signed: 06/23/2022 10:02:15 AM

Document Has Been Signed on 06/23/2022 10:02 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	LOVING LONG LIFE		FACILITY NUMBER:	216803776
ADMINISTRATOR:	DE VENTURA, ANA		FACILITY TYPE:	740
ADDRESS:	57 VALLEJO WAY		TELEPHONE:	(415) 948-9395
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	06/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Care Giver, Rosalina Sanchez Administrator, Ana De Ventura		TIME COMPLETED:	10:20 AM

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), Farhaan Sarangi arrived at Loving Long Life unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Rosalina Sanchez and was granted access into the facility. Administrator, Ana De Ventura arrived 20 minutes later. LPA toured the facility with Care Giver, Rosalina Sanchez. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with bells. Fire Extinguisher was found to be last charged on June 2021 with an expected service this month. Smoke detectors and carbon monoxide detectors were found to be operational during the inspection. 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 non-perishable 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 inspection. 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 garage. Staff have had all PPE training required and have been N95 Fit tested. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LOVING LONG LIFE	FACILITY NUMBER: 216803776
	VISIT DATE: 06/23/2022

NARRATIVE

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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was printed and given to the facility Administrator, Ana De Ventura.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

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