306005581-5-25-2021-22-AS-SHAD-C3CR9X-20210525125016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005581
Report Date: 05/25/2021
Date Signed: 05/25/2021 12:50:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LOVING CARE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	306005581
ADMINISTRATOR:	VIJAY KANASE		FACILITY TYPE:	740
ADDRESS:	2622 W OLIVE AVE		TELEPHONE:	(657) 354-7340
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 3	DATE:	05/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Vijay Kanase		TIME COMPLETED:	01:10 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	This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Norman C. Woodridge for the purpose of conducting an Annual Inspection. LPAs met with Administrator (AD) Vijay Kanase and discussed the purpose of the inspection. During the inspection, LPAs and AD conducted a tour of the inside of the facility, common areas, resident rooms, and kitchen and observed the following: LPAs and AD observed there was 1 staff present, wearing PPE. LPAs observed 3 residents were present. LPAs confirmed all residents were doing well. LPAs inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPAs observed hallways and walkways were free of obstruction. At 9:35 AM, in the attached non-lockable garage, LPAs and AD observed toxins accessible to residents, including laundry detergent, cleaning supplies, and pesticides, with the laundry detergent stored next to food. In the kitchen, LPAs and AD observed knives accessible to residents on the kitchen counter, lockable medication cabinets accessible to residents with the keys left in the locks, keys for other lockable compartments containing dangerous items accessible to residents, and screwdrivers and superglue accessible to residents. During the inspection, AD moved all toxins from the garage to the locked laundry room, moved knives to a locked drawer, removed keys and made them inaccessible, and secured other dangerous items such as screwdrivers and superglue. (Page 1)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOVING CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 306005581
	VISIT DATE: 05/25/2021

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
26
27
28
29
30
31
32

LPAs reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPAs provided technical assistance regarding visitation, COVID-19 signs, resident outings, COVID-19 testing, staff health screenings, and N95 fit testing. LPAs requested and reviewed resident roster, staff roster, staff files, emergency plan, and COVID-19 mitigation plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report as well as appeal rights was discussed with and provided to facility representative.

(Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOVING CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 306005581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

87303 Maintenance and Operation: (a) The facility shall be clean, safe.... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure toxins, knives, medications, and other dangerous items were inaccessible to residents in 2 out of 11 rooms, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/26/2021
	Plan of Correction
1 2 3 4	Licensee immediately secured the toxins, knives, medications, and other dangerous items during today's inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4