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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:13:55 PM

Document Has Been Signed on 07/11/2023 04:13 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
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: 6DATE:
07/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eliesa QioleleTIME COMPLETED:
04:15 PM
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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,Eliesa Qiolele, and explained the purpose of the visit.

The purpose of the visit is to follow up on non-compliance quarterly visit. LPA Martinez toured the facility with Eliesa Qiolel. During today's visit, resident 1 continued to reside at the facility. Eliesa Qiolele reported R1 was in the process of moving out the facility. LPA Martinez reviewed Retention and acceptance and computability of all residents in care with the Licensee and Eliesa Qiolele. LPA Martinez was informed a new client moved into the facility. LPA Martinez requested resident 2's (R2) file. However, R2 did not have a resident file. In addition, resident's bathroom windowscreen was missing during today's inspection. However, facility staff, Eliesa Qiolele added a window screen during today's visit. Deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 07/11/2023 04:13 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/11/2023 at 04:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2023
Section Cited
CCR
87506(a)

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87506(a) Resident Records: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by.
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Facility staff agrees to create a resident file for R1, and conduct training on resident records and medical assessments by POC date 07/25/2023. Training documents and R1's resident file shall be emailed to LPA Martinez by 07/25/2023.
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Based on interviews and file review, LPA only found a Hospital note with R1's DOB. The facility did not have any of the required resident records. This posed a potential 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-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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