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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 04/11/2024
Date Signed: 04/11/2024 11:20:53 AM


Document Has Been Signed on 04/11/2024 11:20 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:SHARP, KAYDIAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
04/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robert BarnettTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould arrived unannounced to conduct a Case Management visit on 04/11/2024 at 9:00 AM, LPA met with licensee, Ratu Vunimatana and explained the purpose of today’s visit. LPA spoke to licensee, Ratu Vunimatana and informed this LPA that the notification was in process, based on the visit to by LPAs to sister facility, to the (LTCO), residents and their responsible party. LPA toured and inspected the physical plant with direct care staff to ensure there are no safety hazards to residents. LPA observed 2 facility staff and the census is 6.

The purpose of today’s visit is to ensure the instructions provided in the Health and Safety Code Section
1569.38 are being followed according to the accusation. The instructions include, but not limited to, the
requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a
conspicuous location advising that an action is pending. The accusation was served on 03/29/2024.
Licensee was previously informed that CCL shall receive copies of the notifications to all residents and/or
responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements.

During the visit, LPA did observe the noticed and accusation posted in a conspicuous location. Per administrator, Ratu he is in process of meeting all requirements for notification.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiencies are being cited.
An exit interview was conducted, and a copy of this report and appeal rights were 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: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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 2


Document Has Been Signed on 04/11/2024 11:20 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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
HSC
1569.38(a)

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1569.38 Posting of licensing reports; disclosure to new residents
(a) Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months, and all licensing reports issued by the department resulting from the most recent annual visit of the department to the facility...
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The licensee agrees to post the accusation in a conspicuous location and provide copies to all residents and their responsible parties by POC date 04/11/2024 by 5:00 PM end of day.
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This requirement was not meet as evidence by:

Base on observation and interview the licensee did not comply with the section above by not ensuring that the accusation was posted in a conspicuous location and copies to residents, which pose an immediate health and safety 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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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