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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700943
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:57:33 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/03/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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: 5DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Queenie RamosTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Parks arrived on Thursday November 3, 2022 to complete the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA completed the infection control domain with Administrator Queenie and facility was found to be in substantial compliance. LPA and Administrator toured the facility together to ensure health and safety of residents in care. LPA observed the garage being used as staff sleeping quarters. Please see 9099-D for citation issued and associated immediate civil penalty.

LPA requested copies of current LIC500, LIC610, and current liability insurance to be sent to the Department by the end of the month.

Exit interview conducted. Appeal rights were printed and given to the facility. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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Document Has Been Signed on 11/03/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: A LOVING SENIOR CARE HOME II
FACILITY NUMBER: 312700943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited

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Fire Safety 87203: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on evidence of a livable space including furniture
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and personal belongings of staff living in the garage.
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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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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