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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005841
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:14:00 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/05/2022 04:14 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LOVING HOME CAREFACILITY NUMBER:
306005841
ADMINISTRATOR:LE, TINFACILITY TYPE:
740
ADDRESS:13402 HOOVER ST.TELEPHONE:
(714) 600-7083
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 5DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Tin Le, Administrator and Estrella Lubi, Live in caregiverTIME COMPLETED:
04:28 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Rosie Quiroz was greeted, and granted entry into the facility by Live in Caregiver (LCG) Estrella Lubi. LPA Rosie Quiroz explained the nature of the visit to (LCG) Estrella Lubi. Licensee/Administrator (L/AD) Tin Le arrived to facility shortly after.
On or about 3:27pm, LPA Rosie Quiroz along with (LCG) Estrella Lubi began the tour of the inside and outside of the facility. There are five residents in care and there are no active COVID-19 cases in the facility. LPA Rosie Quiroz observed one of five residents in living room area watching television and relaxing, and four of five residents in their bedrooms relaxing. Five of five residents appeared to be clean and well taken care of. LPA observed a COVID-19 check in station in the entry of the facility; however LPA Quiroz was not COVID-19 screened upon entering facility. LPA Quiroz did not observe required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. L/AD Tin Le indicated "I will make sure to put some up."
All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food and water in attached garage area. LPA observed the PPE supply in the facility readily available for use. LPA toured the outside of the facility and observed seating and shaded area for resident and visitor's enjoyment. The facility has completed the LIC 808 Mitigation Plan. The plan was received by the Department on July 30, 2021. During today's visit, LPA reviewed and approved LIC 808 Mitigation Plan dated July 30, 2021. LPA was informed that all residents and staff have had their COVID-19 vaccinations and Boosters.
Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with L/AD Tin Le, and a copy of this report, LIC 9102 Technical Violation and LIC 811 Confidential Names was provided to L/AD Tin Le via email.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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