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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:40:00 PM


Document Has Been Signed on 09/28/2023 03:40 PM - 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 IIFACILITY NUMBER:
342700758
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 6DATE:
09/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eliesa QioleleTIME COMPLETED:
03:40 PM
NARRATIVE
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On 09/28/2023 at 2:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to
conduct a case management visit. LPA met with direct care staff, Eliesa Qiolele and explained the purpose of the visit. The census is 6 with 2 care staff. Administrator Ratu Vunimatanu was not present during today's visit.

The purpose of this case management is due to learn deficiencies during complaint investigation with complaint control number 27-AS-20230814135530. LPA Lee toured the facility and checked on residents’ welfare. On 08/29/2023 during complaint visit LPA Lee observed the resident door #3 has a hole. It was learned that resident 1 (R1) kicked (R1) door causing a hole on 08/07/2023. On 08/29/2023, it was learned from care staff that administrator is aware of the hole in resident door #3 and will replace it. During today's visit 09/28/2023 at 2:30 PM, LPA Lee observed resident door #3 still have a big hole. The hole has not been repaired or replace.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of the appeals rights, LIC 809 report, and LIC 809-D page was given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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Document Has Been Signed on 09/28/2023 03:40 PM - 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 II
FACILITY NUMBER: 342700758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidence by:
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Administrator agrees to get resident door #3 repair. Administrator agrees to send picture of resident door #3 paired by POC 10/12/2023 by 5:00 PM by end of day.
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Based on observation and interview the facility is not in good repair. Resident door #3 has been broken for one month and 21 days as of today.
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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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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