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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803776
Report Date: 08/24/2023
Date Signed: 08/28/2023 08:31:41 AM


Document Has Been Signed on 08/28/2023 08:31 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 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:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ana De Ventura, AdministratorTIME COMPLETED:
02:15 PM
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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by staff June Gallen Mateo & Mariel De Vera. Ana De Ventura – Administrator/Licensee was contacted by staff and arrived during the visit. There is a total of 6 residents and 4 with a diagnostic of dementia. There are 2 residents currently on Hospice.

LPA toured the facility on 8/24/2023 at 8:55 AM with staff June Gallen Mateo; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; 4 out of 5 auditory devices were missing and one was falling down. Exiting could present a hazard should residents exit facility unattended (see LIC809-D). Fire Extinguisher was found to be last charged on 6/20/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 118.2 degrees F and 130.1 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 2 resident’s bathrooms while touring facility on 8/24/2023 at 9:10am (see LIC 809-D). 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, however; garage knob lock is facing the kitchen and can be unlocked without any key or device and sharp scissors were left on counter & in unlocked kitchen drawer. Facility has 4 residents with a diagnostic of dementia. (see LIC 809-D) There was a supply of cleaners, hygiene products and paper products available for residents. 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 unless residents refuse - mattress pads must be available at the facility on 8/24/2023. Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776
VISIT DATE: 08/24/2023
NARRATIVE
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A review of 5 resident & two staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM on 8/24/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A).

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

Medications were centrally stored in locked cabinet in the facility living room area; although there was pre poured medications in unlocked kitchen drawer observed by LPA and staff (see pics) at 9:02 AM on 8/24/2023 (see LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 8/24/2023 at 11:45 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 12:45 PM on 8/24/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2023 are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. Ana De Ventura Administrator Certificate # 6027968740 expires on 9/23/2023.

LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; however facility will be changing mailing address, administrator will send in required documents (LIC200 etc..). In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 8/12/2023.



Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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: 08/24/2023
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Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Administrator to update and submit the following documents by 9/14/2023 to CCL:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
Copy of Deed
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2023 08:31 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance & Operation.Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.

This requirement is not met as evidenced by:
Deficient Practice Statement
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***Based on observation the facility failed to have hot water temperature between 105 & 120 F in 1 of 3 resident's bathroom faucets which poses an immediate Health, Safety risk for residents in care. LPA observed hot water temperature in between 118.2 130.1 degrees F.
POC Due Date: 08/25/2023
Plan of Correction
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Facility to ensure hot water temperature is maintained within regulation - 105 TO 120 F. Facility to submit a LIC 9098 seff certification that hot water has been adjusted to be within regulation by POC date of 8/25/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 9/1/2023.
Type A
Section Cited
CCR
87705(f)(1)

87705(f)(1)Care of Persons w/Dementia -The following shall be stored inaccessible to residents with dementia...tools and other items that could constitute danger to resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee failed to maintain toxins locked which poses a immediatelly Safety risk to 4 of 4 residents in care.LPA observed an unlocked garage with toxins & other items.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee to ensure that toxins & other items that constitute danger to residents are inaccessible at all time.Licensee agrees to lock the garage and/or maintain toxins locked at all times. Licensee to submit LIC 9098 self certification that all items that constitute danger to residents are locked and will be locked at all times to CCL by POC date of 8/25/2023.
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/28/2023 08:31 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)

Care of Persons with Dementia.
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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 LPA observed auditory divices on back yard sliding glass door not to be working and bedroom 3 bedroom sliding glass doors not working.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee to make sure all alarms are turned on and working, or re applied. POC Licensee to send in pictures or receipts for the new alarms. Send to CCL by POC due date of 8/25/2023.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by LPA and staff (see pic) medication for resident was in kitchen drawer without a lock. The medication shoud be centrally stored as required by regulations. This is a health & safety risk and/or a personal rights risk to residents in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator to submit documentation they understand regulation by POC due date of 8/25/2023 & then documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance.
POC due date 9/1/2023 to Community Care Licensing to clear the citation.
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/28/2023 08:31 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
87465(h)(5) Incidental Medical and Dental Care -(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observed (see pic) resident medication had been prepoured into plastic container and left in unlocked kitchen drawer. Medications are to remain in original containers. This is a potenitial risk to health & safety and/or personal rights risk to residents in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator to ensure that medications are not transferred between containers at any time, per regulation, medications are to remain in origianl containers. Licensee to ensure all staff are retrained in medication procedures, submit proof of training by 9/1/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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