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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803776
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:54:08 PM


Document Has Been Signed on 08/21/2024 03:54 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
SANTA ROSA RO, 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:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee/Administrator, Ana De VenturaTIME COMPLETED:
04:05 PM
NARRATIVE
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At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Ana De Ventura. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 ambulatory residents, of which 3 residents can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 6 Residents in care and 3 staff members on-site.

At approximately 1:00PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:10PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 2 of 4 sinks in facility were found to be out of compliance with Title 22 regulations measuring at 125.0F and 125.7F (this deficiency has been cited, see LIC809D, regulation 87303(e)(2)). Facility's fire extinguishers were last inspected July 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted July 2024.

LPA reviewed staff files, resident files, and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. During resident file review, LPA observed that there are currently 5 non-ambulatory residents and 1 ambulatory resident residing in facility (this deficiency has been cited, see LIC809D, regulation 87202(a)). Licensee to submit new facility sketch identifying room status so a new fire clearance can be requested.

Continued on LIC809C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776
VISIT DATE: 08/21/2024
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Continued from LIC809

Administrator Certificate for Ana De Ventura (6027968740) was shown to be expired with an expiration date of 09/23/2023. LPA reviewed facility documentation stating that Licensee submitted their renewal paperwork to the Administrator Certification Bureau and is pending.

LPA is requesting the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 09/21/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/21/2024 03:54 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, Licensee did not comply with the section cited above. LPA observed that there are currently 5 non-ambulatory residents and 1 ambulatory resident which is out of compliance with facility license and fire clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee to submit new facility sketch for a new fire clearance request to Community Care Licensing (CCL) by POC due date of 08/22/2024.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/21/2024 03:54 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LOVING LONG LIFE
FACILITY NUMBER: 216803776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee did not comply with the section cited above in 2 of 4 sinks. LPA observed that 2 of facility's water temperatures measured 125.0F and 125.7F. This poses a potential health and safety risk to residents in care.
POC Due Date: 08/31/2024
Plan of Correction
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Licensee to submit a water temperature log documenting the Facility's water temperature for 10 days. Water temperature to be taken once in the morning and once in the afternoon. Temperature Log to include the following: date, time, sink location, and temperature. Log to be submitted to the Department for review and approval by POC due date of 08/31/2024.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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