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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:29:30 PM

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 IIFACILITY NUMBER:
342700758
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 4DATE:
07/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ratu Vunimatana TIME COMPLETED:
12:30 PM
NARRATIVE
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 07/07/2021 at 9:45 AM. LPA met with the facility licensee, Ratu Vunimatana, and explained the purpose of the visit.

The purpose of the visit is to follow up on an incident report received on 06/30/2021. The report stated on 06/27/2021, resident 1 (R1) eloped from this facility. R1's LIC 602 Physician's Report states resident is not able to leave the facility unassisted. On 06/27/2021, R1 was out of the facility for a period of 2-3 hours and was found down the street by facility staff. It was learned it was unknown when R1 left the facility. Moreover, LPA Martinez interviewed witness 1 (W1) on 07/07/2021. W1 reported it was unknown when R1 left the facility. R1 has previously left the facility unassisted, and it was reported R1 would walk to the near by park. Moreover, R1's assessment did not include an elopement prevention plan, and the facility failed to implement resident observation checks.

Based on the above information the facility did not implement an elopement prevention plan and did not provide observation checks to prevent elopements. As a result, The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Deficiency can be found on the 809D report.

Exit interview was conducted and appeal rights, 809 report, and 809D report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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87464(f)(1) Basic Services Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidence by:
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Based on interviews and file review, the licensee did not ensure to implement a elopement prevention plan and to implement elopement observation checks for R1. R1 successfully left the facility unattended on 06/27/2021 and was out of the facility for 2-3 hours before being found. This posed an immediate health and safety risk to R1.
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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) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
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