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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:14:09 PM


Document Has Been Signed on 03/22/2024 03:14 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:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Eliesa Quolele TIME COMPLETED:
03:25 PM
NARRATIVE
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On 03/22/2024 at 1:18 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit. LPA Lee met with direct care staff, Eliesa Quolele and explained the purpose of the visit. LPA Lee called administrator Ratu Vunimatana and spoke to administrator via telephone and explained the purpose of today visit. The census is 6 with 1 facility staff present during today’s visit. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. For today's visit the administrator was not present. During today's visit client 1 (C1)'s Alta Regional Service Coordinator, John Munzo was present for the visit.

The purpose of today's visit, is in response to a 3-day eviction and a 30-day eviction notice. The department received a 3-day eviction and a 30-day eviction noticed from administrator on 02/27/2024. It was learned that on 02/02/2024 (C1) slapped (C2) in the face when (C2) was sleeping. The facility staff called the police and (C1) was then taken to Sutter Hospital for further evaluation. On 02/05/2024 (C1) was then transferred to Heritage Oaks Hospital. On 02/27/2024, administrator called (C1) responsible party to ask for (C1)’s responsible party’s email address to email (C1)’s 30-day eviction notice. On 02/28/24, the administrator emailed both (C1)’s Alta Regional Service Coordinator and the CCLD (C1)'s eviction notice.

It was also learned that the administrator did not notify the department and get approval prior to issuing (C1) the 30-day eviction. Upon reviewing the 30-day eviction it was not a lawful eviction, as a result, the facility did not follow the eviction procedures. LPA Lee reviewed client file and record review revealed that LIC 603 Preplacement Appraisal Information and a Pre-Placement Questionnaire was completed; however, there was no date documented; therefore, it is unclear when the Pre-placement was completed.

The following deficiency was observed and cited form California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report, LIC 809-D and appeal rights were given to care staff Eliesa Quolele.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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 03/22/2024 03:14 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: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87244(c)

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87224 Eviction Procedures
(c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.
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Licensee agrees to: review eviction regulations by POC date 04/05/2024. Licensee will email LPA a written statement stating eviction regulations have been reviewed and understood and email to LPA Lee by POC by 5:00 PM by end of day.
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This requirement is not met as evidenced by:

Based on file review and interviews, the licensee did not ensure to notify the department and get approval prior to issuing (C1) the 3-day and 30-day eviction. As a result, the facility did not follow the eviction procedures. This posed an immediate health and safety risk to C1.
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 Licensee also agrees to notify the depart and get approval to any 3-day evictions and 30-day evictions.

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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: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2