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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:45:21 PM


Document Has Been Signed on 08/28/2024 01:45 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: 5DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Eliesa QioleleTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced at Love and Comfort on 8/28/24. LPA Vincent Moleski spoke with facility administrator Ratu Vunimatana over the phone and explained the purpose of the visit.

On arriving LPAs Moleski and Williams and LPM Richardson observed both gates in the front of the facility were locked with dead bolt and chain. LPA Williams interviewed a staff member (S1) and they said that the gates are locked all the time.

LPAs received an incident report on 8/6/24 stating that a resident (R1) went out to smoke on 8/5/24 and never came back. S1 said that S1 went out with R1 to sweep inside and outside of the gate. Caregiver S1 walked to the other side of the yard and R1 went out of the gate. S1 said that they went to look for the resident R1 on 8/5/24 throughout the surrounding areas and did not find the resident. LPA Williams and Moleski reviewed resident notes and observed documentation dated 8/5/24 indicating that R1 at 9:50 AM opened the gate and went out in his wheel chair. LIC602 states that R1 is not able to leave the facility unassisted. R1 has still not returned, according to S1.

This facility is being cited per 22 CCR sections 87411(a) and 87202(a). LPA assessed civil penalties for fire clearance violations and lack of supervision. Civil penalties are being assessed for $500 for each citation.

An exit interview was held with Vunimatana, who said that staff member Eliesa Qiolele could sign this report in his absence. Appeal rights and a copy of this report were left with Qiolele.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 08/28/2024 01:45 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance
"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal..." This requirement was not met as evidenced by:
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Licensee agrees to unlock all gates and to provide a signed statement that all gates will remain unlocked from now on. Please email signed statement to Holly.williams@dss.ca.gov within POC due date.
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Based on observation and interview, the main egress was locked, which prevents residents or staff from escaping in event of a fire, which is a violation of this facility's fire clearance, which poses an immediate health, safety, and/or personal rights risk.
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Type A
08/29/2024
Section Cited
CCR87411(a)

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87411 Personnel Requirements
"(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs..."

This requirement was not met as evidenced by
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Licensee agrees to provide a written plan of correction by POC due date. Holly.williams@dss.ca.gov
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Based on interview and record review, staff were not able to supervise a resident and allowed the resident to enter the community without supervision, despite their LIC 602 stating that they could not do so, which poses an immediate health, safety, and/or personal rights risk.
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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: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2