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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:29:02 AM


Document Has Been Signed on 09/19/2024 11:29 AM - 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:CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 2DATE:
09/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
12:00 PM
NARRATIVE
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On 9/19/24 at 9:15am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure all previous deficiencies have been corrected and all written plans of correction have been completed.

LPA met with the licensee and discussed plans of correction. LPA was informed no current written plans of correction have been completed but the facility has taken the following action.
  • facility has informed placement agency they will no longer be accepting residents for placement who do not meet the facility's criteria for placement including being over the age of 60 and not having any diagnosed mental disorder other than dementia. - Facility will communicate this as part of their written plan of correction.
  • Staff bedroom will be restored to a resident bedroom and identified for use as a bedridden resident. Staff member currently occupying bedroom will move out on today's date, 9/19/24. Written plan to be submitted as part of the Plan of Correction.
  • Vendor Yolo Hospice will conduct personal rights training for staff members. written plan of correction will include the future date identified for training.
  • door has been removed, Licensee will submit as written plan of correction with statements of staff supervision will be provided to manage any resident behaviors that may be a danger to themselves or others.

As the licensee has not yet completed all plans of correction and is over 10 days since facility was cited, facility will be recited and plans of correction will be completed by the POC due date or will subject to immediate civil penalties for a failure to correct. Report Continued on LIC 9099-C.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND COMFORT ELDERLY CARE
FACILITY NUMBER: 342700731
VISIT DATE: 09/19/2024
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Per California Code of Regulations, Title 22 the following deficiencies are cited. Exit interview conducted and a copy of this report and appeal rights are left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 11:29 AM - 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
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 a written plan of correction stating they will abide by the original plan of operation approved by the department when facility was licensed and they will no longer accept residents under 60 with mental diagnoses other than dementia.
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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
09/20/2024
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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Staff member currently occupying bedroom with fire clearance for non-ambulatory residents will vacate the room and will be restored to a resident bedroom capable of housing a bedridden residents. Facility will also submit a written plan of correction stating all bedrooms are licensed for resident care and will not be used for other purpose without department approval.
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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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 11:29 AM - 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
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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Facility will provide a written statement to the department that the facility will return to their original 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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Type A
09/20/2024
Section Cited
CCR87307(c)

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Personal Accommodations and Services: Individual privacy shall be provided in all toilet, bath and shower areas. This requirement was not met as evidenced by, R1's statements and LPAs observations of R1 sharing a room with another resident with a bedside
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Facility will ensure the privacy for all residents while toileting or performing ADLs at the facility and will submit a written plan of correction ensuring all residents who may utilize a bedside commode will be afforded a private room and privacy when toileting.
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commode present that R1 was not provided privacy when toileting at the facility which poses an immediate health, safety and 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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 11:29 AM - 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by R1's statements and LPA observations that R1 had a shared room and lacked
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Facility will contract for additional personal rights training with a vendor, (Yolo Hospice) for all staff and provide a training date to the department by the POC due date.
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privacy and was not treated with dignity by facility staff and other residents which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
09/20/2024
Section Cited
CCR87468.1(a)(6)

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Personal Rights of Residents in All Facilities: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against
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Facility will provide a written statement that the kitchen will not be locked for any purpose and that any resident who may poses a danger to themselves or other will be supervised appropriately
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intruders, with permission from the Department. This requirement was not met as evidenced by: Statements by S1 confirming the kitchen is locked overnight and residents to not have access to the kitchen, living room or back yard during overnight hours and are restricted to the bedrooms and hallway that leads to the front door which poses an immediate health, safety and 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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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