306005581-5-23-2024-22-AS-EKIM-D5JW5E-20240523165900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005581
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:59:56 PM

Document Has Been Signed on 05/23/2024 04:59 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
ORANGE COUNTY RO, 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: 6	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Vijay Kanase		TIME COMPLETED:	05:10 PM

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On May 23, 2024 at 2:05PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry with Administrator (AD) Vijay Kanase and explained the purpose of the visit.

The facility is licensed to operate for five (5) non-ambulatory of which one (1) may be bedridden, and Hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, dining room, kitchen, and outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Kanase. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 107.0 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has one (1) fire extinguisher that is charged and mounted in the kitchen. The fire extinguisher was serviced on January 8, 2024, The facility has smoke detectors and carbon monoxide detector that were operable. The facility conducted a Fire/Safety Drill on March 5, 2024. A working telephone (657-354-7340) remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOVING CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 306005581
	VISIT DATE: 05/23/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA Kim observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Administrator Certificate for Vijay Kanase is valid until May 1, 2025.

LPA Kim conducted an audit of residents #4-6 service files, and staff #1-4 personnel files were in order and completed.

Due to time constraint a continuation of this inspection will be conducted at a later date. LPA will conduct record review for residents #1-#3, medication review, bed rail hospice care plan for residents #4-#6, resident interviews, staff interviews, and complete first aid kit check at a later date.

An exit interview was conducted, and a copy of this report was provided to Administrator Vijay Kanase.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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