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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 04/09/2024
Date Signed: 04/09/2024 08:50:13 AM


Document Has Been Signed on 04/09/2024 08:50 AM - 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: 5DATE:
04/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH: Eliesa QioleleTIME COMPLETED:
09:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee and (LPA) Arielle Pascua arrived unannounced to conduct a Case Management visit on 04/09/2024 at 8:00 AM, LPAs met with direct care staff Eliesa Qiolele and explained the purpose of today’s visit. LPA Lee called and spoke to administrator, Ratu Vunimatana and informed this LPA that the noticed was not sent to the (LTCO), residents and their responsible party. LPAs toured and inspected the physical plant with direct care staff to ensure there are no safety hazards to residents. LPAs observed 2 facility staff and the census is 6 with 1 resident in the hospital.

The purpose of today’s visit is to ensure the instructions provided in the Health and Safety Code Section
1569.38 are being followed according to the accusation. The instructions include, but not limited to, the
requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a
conspicuous location advising that an action is pending. The accusation was served on 03/29/2024.
Licensee was previously informed that CCL shall receive copies of the notifications to all residents and/or
responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements.

During the visit, LPAs did not observe the noticed and accusation posted in a conspicuous location. Per administrator, Ratu it was stated that he has received the accusation and has not reviewed the documents and was not aware that it needed to be posted in a conspicuous area.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiencies are being cited.
An exit interview was conducted, and a copy of this report LIC 809 and LIC 809-D was provided to care staff Eliesa Qiolele.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 04/09/2024 08:50 AM - 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
1569.38(a)

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1569.38 Posting of licensing reports; disclosure to new residents
(a) Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months, and all licensing reports issued by the department resulting from the most recent annual visit of the department to the facility...
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The licensee agrees to post the accusation in a conspicuous location and provide copies to all residents and their responsible parties by POC date 04/09/2024 by 5:00 PM end of day.
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This requirement was not meet as evidence by:

Base on observation and interview the licensee did not comply with the section above by not ensuring that the accusation was posted in a conspicuous location and copies to residents, which pose an immedicate health and saftey to residents in care. LPAs stated that he was unaware that it needs to be posted since he has not review the accusation.
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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