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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 05/06/2022
Date Signed: 05/06/2022 04:02:39 PM


Document Has Been Signed on 05/06/2022 04:02 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:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Ratu VunimatanaTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual inspection on 05/06/2022. LPA met with Ratu Vunimatana and explained the purpose of the visit. Ratu Vunimatana is the Administrator and holds certificate #6054043740 that expires on 11/24/2023

This facility is a 2 story building licensed to serve (5) non-ambulatory residents. of which 1 may be bed ridden at any time. The facility has a hospice waiver for 1 resident. The facility is allowed a total of 6 residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 05/06/2022 Thermostat observed at (74) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.
The following forms need updating and were received during today's visit on 05/06/2022
LIC 308, LIC 500, LIC 610E, LIC 9020, Admin Certificate, Liability insurance certificate
No deficiencies were cited during today's inspection. Exit interview held with Ratu Vunimatana and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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