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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700944
Report Date: 12/18/2020
Date Signed: 12/18/2020 03:49:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A LOVING SENIOR CARE HOME I LLCFACILITY NUMBER:
312700944
ADMINISTRATOR:RAMOS, QUEENIE R.FACILITY TYPE:
740
ADDRESS:501 HEATHMORE CT.TELEPHONE:
(510) 427-9904
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 5DATE:
12/18/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Queenie RamosTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via Webex to conduct a virtual prelicensing visit on 12/18/2020 due to COVID-19 and pre-cautionary measures.

LPA virtually toured the facility with Administrator Queenie Ramos. This facility has a fire clearance for 6 nonambulatory residents. There are 5 bedrooms and 3 bathrooms. Facility has audible alarms on outside doors. All bedrooms contain the required furniture. Bathroom water temperatures are recorded within 105 - 120 degrees F. Showers have required nonskid mats. Kitchen is clean and organized. All knives and sharp objects are kept locked and inaccessible to clients. All appliances in the kitchen are observed to be clean and operational. Toxins and cleaning supplies are locked under the kitchen sink. Medications are kept locked in hallway cabinet. Wash and dryer are located in separate room by the garage and are clean and noted to be operational. There are locked cabinets in the laundry room for detergent and additional cleaning supplies. Backyard was clear of debris and hazards. Backyard gates are in working order.

Facility has a current inspection for the fire extinguisher. Facility has a fully stocked first aid kit. All staff and resident binders are kept in hallway cabinets.

Component III has been completed at this time with Administrator Queenie.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report emailed to the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020
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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