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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700321
Report Date: 07/29/2020
Date Signed: 07/29/2020 03:37:08 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 AND DIVINE HOME CAREFACILITY NUMBER:
342700321
ADMINISTRATOR:IVANCICH, LARRYFACILITY TYPE:
740
ADDRESS:304 OAK CANYON WAYTELEPHONE:
(916) 945-0259
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 6DATE:
07/29/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Tyler Ivancich (Administrator) TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Konnor Leitzell contact Tyler Ivancich (Administrator) at 2:50p.m. on 7/29/2020 via telephone regarding an incident and death report submitted on 7/24/2020. LPA asked administrator to describe leading up to sending R1 to hospital.

Admin explained he was notified at 6:30a.m. by staff of mucus gathering around R1's mouth. Staff was working the night shift and heard light coughing from R1, but checked and noted it was not a cause for concern. Staff has worked at facility for over two years. Tyler was notified and arrived around 7:00a.m. and assessed R1. No foam or mucus was observed at that point. Administrator stated when assessing R1, noticed irregular breathing and contacted 911 for immediate transport to Mercy Folsom. Resident was previously diagnosed with pneumonia in early March. Administrator stated resident was "her normal spunky self" the day prior, but when assessed in morning resident was slightly below baseline.

LPA asked Administrator if resident was on hospice and was informed was not.

LPA requested the following document by COB 7/31/2020
  • Daily Charting notes from March-Present
  • LIC 602 - Physicians report
  • Hospital Discharge papers for March visit.

Exit interview conducted and form emailed to Administrator to review, sign, and return by COB 7/29/2020.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020
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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