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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700943
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:38:14 PM


Document Has Been Signed on 06/28/2022 01:38 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:A LOVING SENIOR CARE HOME IIFACILITY NUMBER:
312700943
ADMINISTRATOR:RAMOS, QUEENIE R.FACILITY TYPE:
740
ADDRESS:1190 EARLTON LN.TELEPHONE:
(510) 427-5165
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 4DATE:
06/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Queenie R Ramos, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Michael Hood met with Administrator, Queenie Ramos, to conduct an inspection.

During inspection, LPA conducted an interview with staff member (S2) and discovered that resident (R1) had a change in condition that was not addressed with a reassessment for R1. R1's most current Physician Report (LIC 602) was dated 6/7/2018 and indicated that R1 was able to independently transfer to and from bed. However, interviews with S2 and staff members S3 and S4 indicated that R1 received transfer assistance to and from bed.

During inspection, LPA observed staff members not wearing masks while on the premises. LPA provided technical assistance regarding staff not wearing masks while on the premises.

LPA issued technical violations pertaining to the information above. Facility will ensure that residents are receiving reassessments when a resident experiences a change in condition. Facility will also ensure that all staff and visitors wear a mask while on the premises.

Exit interview was conducted with Administrator. A copy of this report was provided. The Administrator’s signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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