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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700943
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:24:54 PM


Document Has Been Signed on 11/15/2023 01:24 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:RAMOS, QUEENIE R.FACILITY TYPE:
740
ADDRESS:1190 EARLTON LN.TELEPHONE:
(510) 427-5165
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 3DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Queenie RamosTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday November 15, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (3) and staff files (3). All resident files contained the required paperwork. All staff files contained the required paperwork and training. First aid kit was fully stocked. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed.

LPA Parks and Administrator Queenie toured the facility together 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.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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