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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 06/25/2025
Date Signed: 06/25/2025 11:51:35 AM

Document Has Been Signed on 06/25/2025 11:51 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/
DIRECTOR:		CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
06/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Issac RatuTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 6/25/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management deficiencies inspection to address deficiencies observed during a complaint investigation.

LPA requested the file and medication administration records (MARs) for former Resident R1 (See confidential names list, LIC 811 dated 6/25/25) LPA was provided the file for former resident but the facility did not retain the MARs for R1 after leaving the facility. Per California Code of Regulations, Title 22 facilities are required to retain resident records for three years after the termination of services. LPA was unable to review files and staff present states they do not have the files requested.

Additionally, LPA observed that the facility is administering medications to R2 without a physician's order. LPA observed the facility has been administering over the counter Claritin for several months without a physician's order. additionally, the facility has been administering the Claritin two times daily which in excess of the recommended dose not to exceed one pill in 24 hours. LPA has also observed the facility has not been following the physician's order for daily blood glucose monitoring.

Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. An immediate civil penalty was also issued during today's inspection.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/25/2025 11:51 AM - It Cannot Be Edited


Created By: Kevin Gould On 06/25/2025 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2025
Section Cited
CCR
87465(a)(5)(A)

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Incidental Medical and Dental Care: Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by LPA observed an over the counter medication for R1 did not have a
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Licensee will arrange for medication training for all staff members and provide copies of the training materials and staff signatures indicating training has been completed by the POC due date of 6/26/25
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 physician's order for the over the counter allergy medication and was administering the medication in excess of recommended dosage (2 times daily) which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
06/30/2025
Section Cited
CCR87506(e)

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Resident Records: Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by LPA requested former resident's medication administration records and the facility did not retain the
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Licensee will provide a written plan or correction indicating the steps the facility will take to ensure all former resident file are complete, well organized and retained for the required period of time identified by the department. POC due date is 6/30/25
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records or could not locate their whereabouts which poses a potential 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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