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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700901
Report Date: 07/01/2024
Date Signed: 07/01/2024 03:31:02 PM

Document Has Been Signed on 07/01/2024 03:31 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:A LOVING AND JOYFUL HOME RCFEFACILITY NUMBER:
312700901
ADMINISTRATOR/
DIRECTOR:		HEYDON, ANITAFACILITY TYPE:
740
ADDRESS:609 HERNANDEZ LANETELEPHONE:
(916) 918-2429
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 5DATE:
07/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Anita HeydonTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 7/1/24, Licensing Program Analyst (LPA Kevin Mknelly, arrived for a case management visit. LPA notified caregiver of the reason for the visit. Admin was contacted and arrived to assist.

LPA is following up on the citation issued on 6/25/24.
LPA conducted interviews with 5 of 5 residents and interviewed the Administrator.

During interviews it was found that one resident (R1) has a prohibited health condition for which an exception has not been granted by the department. R2 is receiving wound care and Admin found that they exceed allowable stage level..

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

LPA reviewed the report with the Administrator. Report copy and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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Document Has Been Signed on 07/01/2024 03:31 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 07/01/2024 at 02:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A LOVING AND JOYFUL HOME RCFE
FACILITY NUMBER: 312700901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
87615(b)(2)

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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
(2) Gastrostomy tubes.
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Licensee will submit either a request for an exception or notice of discharge for R1 by the plan of correction (POC) date of 7/2/24.
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This requirement was not met based on interview and record that found R1 was admitted 6/17/24 with a g-tube. and R2 has greatwer than stage II pressure injuries.
This posed and immediate risk to R1's health.
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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