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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700943
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:28:41 PM

Document Has Been Signed on 12/11/2024 01:28 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 SENIOR CARE HOME IIFACILITY NUMBER:
312700943
ADMINISTRATOR/
DIRECTOR:
RAMOS, QUEENIE R.FACILITY TYPE:
740
ADDRESS:1190 EARLTON LN.TELEPHONE:
(510) 427-5165
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Queenie RamosTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Hiratsuka to conduct the unannounced annual inspection.

LPA toured the facility with Administrator Queenie Ramos to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

Two resident and two staff files were reviewed.

A couple of topics were discussed.

The following shall be updated and submitted to Community Care Licensing by the end of the month:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
-LIC 309 administrative organization

No deficiencies cited. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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