342700758-5-14-2021-27-AS-TTRG-C2ZPKM-20210514112321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 05/13/2021
Date Signed: 05/14/2021 11:23:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LOVE AND COMFORT II		FACILITY NUMBER:	342700758
ADMINISTRATOR:	VUNIMATANA, RATU		FACILITY TYPE:	740
ADDRESS:	320 BOWMAN AVE		TELEPHONE:	(916) 832-3626
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95833
CAPACITY:	6	CENSUS: 6	DATE:	05/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mike Her, Administrator Assistant		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong arrived at this facility unannounced on 05/13/2021 at 9:15 AM to conduct an annual inspection visit. LPAs met with Administrator Assistant Mike Her and explained the purpose of the visit. Administrator holds current certificate # 6054043740 and expires on 11/24/2021. The facility is licensed for 6 ambulatory, which 5 may be non-ambulatory and 1 may be bedridden. This facility has a hospice waiver for 1. There is currently 6 resident who reside at this facility. The LPA's toured the facility with the administrator assistant, Mike Her, on 05/13/2021 at 9:15 AM. LPA's inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA's also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND COMFORT II	FACILITY NUMBER: 342700758
	VISIT DATE: 05/13/2021

NARRATIVE

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The facility common areas were furnished and sanitary. The facility has a public telephone, and the facility has implemented virtual visits and outside visits. The facility has Covid-19 posting throughout the facility. The facility has submitted a mitigation plan to CCLD and was approved. The facility has one central entry point, and the facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

The Facility has an adequate supply of food and has utensils and dishware. The facility water temperature is 120 degrees. The facility living room is furnished and sanitary. Facility bathrooms are sanitary. Facility bedrooms are furnished and sanitary. Smoke and carbon detectors are up to date. Fire extinguisher does not have a service tag. Fire extinguisher is not up to date and fully charge. The exterior emergency exit door is clear of derbies. The facility first aid kit is up to date. Facility files are up to date.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 was assessed on 5/13/2021 in regard to the facility not having the fire extinguisher up to date.

Exit interview was held and a report was given to Mike Her. Appeal rights given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND COMFORT II	FACILITY NUMBER: 342700758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review. The licensee did not ensure fire extinguisher is up to date. Fire extinguisher did not have a sale receipt or fire department servicing tag. In addition, the fire extinguisher meter showed the fire extinguisher was not fully charged.
	POC Due Date: 05/13/2021
	Plan of Correction
1 2 3 4	Facility stafff will purchase a fire extinguisher after inspection visit. Facility staff will send picture of new fire extinguisher installed. Facility staff will email picture to LPA by COB.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC809 (FAS) - (06/04)

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