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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700711
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:18:41 PM


Document Has Been Signed on 01/26/2024 02:18 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:LOVING CARE SENIOR LIVINGFACILITY NUMBER:
342700711
ADMINISTRATOR:RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:4436 JAN DRIVETELEPHONE:
(916) 844-7271
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kelly ConleyTIME COMPLETED:
02:24 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a require annual inspection utilizing the care tool. LPA met with house manager, Kelly Conley, and explained the purpose of the visit.

Today's census is six residents with two residents on hospice services, compliance to facility's licensure.

LPA and House Manager conducted a tour of the facility. Areas toured included but limited to: six private resident rooms, five bathrooms, kitchen and common areas. LPA observed four residents present in the common areas and two residents in their bedrooms. LPA observed the facility to be 76* at a comfortable temperature for residents in care. LPA observed the facility to have 2+ days of perishable and 7+ days on nonperishable foods. LPA observed facility to be free from safety hazards.

LPA and House Manager discussed facility submitting R1's exception request. LPA provided a copy of California Code Regulation 87616 Exceptions for Health Conditions. Additionally, LPA and House Manager discussed annual fees as it is not up to date.

LPA conducted a file review for personnel and residents in care. Care tool completed and no deficiencies cited.

At this time, LPA is requesting a copy of LIC 500 and facility liability insurance.

Exit interview and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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