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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881012
Report Date: 11/04/2024
Date Signed: 11/04/2024 02:16:36 PM

Document Has Been Signed on 11/04/2024 02:16 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LOVABLE HOME CARE FOR DISABLED ADULTSFACILITY NUMBER:
331881012
ADMINISTRATOR/
DIRECTOR:		SEYMORE, TONISHAFACILITY TYPE:
735
ADDRESS:26594 BYRON CIRCLETELEPHONE:
(714) 341-4542
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 4DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Tonisha Seymore AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analysts(LPAs) Ferrer Sabarias, Abdoulaye Zerbo and Andrei Castillo arrived at 11:47 AM. to conducted an unannounced visit for a required annual inspection. The LPAs were greeted by the Administrator Tonisha Seymore notified her of the purpose of the visit and were granted to enter the facility to conduct the inspection.

Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.

Physical Plant and Environmental Safety: The facility is maintained at a comfortable temperature. The facility consists of 4 resident bedrooms, and 2 bathrooms, living room, kitchen, backyard. The bedrooms are furnished with TV, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The hot water temperature in the bathroom and kitchen read at 137.1 degrees, Licensee is regulating the temperature of the water and will submit a proof of correction. . The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to the resident. According to the Administrator there are no firearms kept in the home. The facility has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order, last date serviced [10/4/24].

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on [9/26/24], which met department requirements. All facility exits were clear of obstructions.
Continue on LIC809C
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LOVABLE HOME CARE FOR DISABLED ADULTS
FACILITY NUMBER: 331881012
VISIT DATE: 11/04/2024
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Continue from LIC809

P&I- was reviewed. LPAs observed that the facility maintains a separate log for each individual’s monies. Money counted, count was accurately reflected on the ledger.


Record Review and Resident/Staff Files: LPAs reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPAs reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.



During the inspection, no deficiencies were observed. An exit interview was conducted, and a copy of the report was provided to Administrator .Tonisha Seymore
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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