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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:08:19 PM


Document Has Been Signed on 09/05/2024 03:08 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LOVE AND COMFORT ELDERLY CAREFACILITY NUMBER:
342700731
ADMINISTRATOR:SHARP, KAYDIAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Isikeli TuikentatubaTIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/5/24 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould and department representative Shariff Osman conducted an unannounced Case Management inspection to address deficiencies observed in facility operation. LPA met with Licensee, Ratu Vunimatana and informed him of the concerns of the department and discussed a potential meeting with the department to discuss the changes of facility operation.

LPA Gould observed the facility, in contradiction to their own plan of operation, are now accepting residents with a diagnosed mental health disorders. Per their approved plan of operation, the facility would only accept residents with a diagnosis of dementia and those with a mental health diagnosis beyond dementia, would not be admitted to the facility. Several of the residents admitted to the facility have a history of self harm and may pose a danger to themselves or others and there is no identified precautions documented in the plan of operation to ensure residents safety.

LPA also observed the facility is currently not in compliance with the facility fire clearance as approved by the local fire department and community care licensing. Per the approved fire clearance, the facility is approved for 6 non-ambulatory residents and one bedridden resident in room #5. As part of LPAs observations, bedroom 5 has been converted to a staff bedroom and the facility no longer has a capacity for bedridden clients in its current configuration.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 09/05/2024 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND COMFORT ELDERLY CARE
FACILITY NUMBER: 342700731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
87208(a)

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Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of
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Facility will provide an update plan of operation describing who the facility will serve and a written plan of correction indication the steps facility must take if there are any changes to the population accepted
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operation which would affect the services to residents shall be submitted to the licensing agency for approval...this requirement was not met as evidenced by LPA review of resident records and which show several residents with a diagnosed mental health disorder and the facility plan of operation specifically states they will not accept that population which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
09/06/2024
Section Cited
CCR87202(a)

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Fire Clearance: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the
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Facility will submit and updated facility sketch clearly identifying the use, capacity and desired ambulatory status for each bedroom, the facility will also submit and updated fire clearance request and provide a check to the department for the updated fire clearance.
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 applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: LPA observations that the identified bedridden room (room 5) has been converted to a staff bedroom without an updated fire clearance or notification to the department which poses an immediate health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/05/2024 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND COMFORT ELDERLY CARE
FACILITY NUMBER: 342700731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
87208(a)(11)

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Plan of Operation: If the licensee intends to admit and/or specialize in care for one or more residents who have a documented history of behaviors that may result in harm to self or others, the facility plan of operation shall include a description of precautions that will be
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See previous citation, facility will be required to review and resubmit an updated plan of operation by the poc due date for department approval or provide a written statement to the department that the facility will return to their origional plan of operation and only served the population identified in their approved plan of operation
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taken to protect that resident and all other residents. This requirement was not met as evidenced by LPA review of the plan of operation and review of resident records where there are are residents in place with a history of self harm and suicidal attempts/ideation and no documented precautions in place or documented as part of the facility plan of operation to ensure resident safety.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3