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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 04/11/2023
Date Signed: 04/12/2023 08:30:16 AM


Document Has Been Signed on 04/12/2023 08:30 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 AC/SC, 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:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ratu Vunimatana and Eliesa QioleleTIME COMPLETED:
04:44 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual inspection on 04/11/2023 at 2:00 PM. LPAs met with Ratu Vunimatana and Eliesa Qiolele and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents, which 1 may be bedridden, and the facility has an approved hospice waiver for one.

LPAs toured the facility with Eliesa Qiolele on 04/11/2023 at 4:00 PM.

LPAs reviewed 6 out of 6 resident files, and 5 resident files were up to date. The Administrator was in the process of completing resident 6 file. Resident 6 moved into the facility today. LPAs reviewed 2 resident medication records, and it was learned that resident 1's Medication Administration Record (MAR) was incomplete. Resident 1's (MAR) did not have all of their medication recorded. In addition, R1's April MAR was incomplete, and it is unknown if medication was administered to R1 during 04/11/2023 morning medication administration. The first aid kit was complete. LPAs reviewed 3 out of 3 staff files, and they were complete. It was also learned there are 4 residents under the age of 60, and all have different levels of care. As of today, the Licensee will not accept any other resident under the age of 60. Resident 5 (R5) an Alta Regional client will be moving out of the home due to a higher level of care requirement.

The facility is sanitary and clean, and the facility is furnished. The facility water temperature measured at 144 degrees. LPA Lee tested the water, and the water was too hot to touch. The facility last fire drill was last month. The smoke and fire extinguisher was up to date. The facility had an adequate food supply, and the exterior resident patio furniture was in good repair. The back yard lawn will be mowed this weekend. Based on today's annual inspection, the facility has received deficiencies which can be found on the 809-D page. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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 3


Document Has Been Signed on 04/12/2023 08:30 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 AC/SC, 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited

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87465(a)(4) Incidental Medical and Dental Care:A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: based on observation and file review:
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 Staff agrees to conduct Incidental medical and dental training for all staff by POC date 04/25/2023. Staff agrees to email training documents to LPA Martinez by POC date 04/25/2023 5 PM.
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The Licensee did not ensure R1 MAR sheet was maintained. 04/11/2023 Morning Medications MAR section was not initialed, and it is unknown if medication were administered per care staff. This posed a potential health and safety risk to R1.
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Type B
04/25/2023
Section Cited

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87465(6)(a-f) Incidental Medical and Dental CareThe licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:..The name of the prescribing physician. The drug name, strength and quantity.... This requirement was not met as
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Staff agrees to conduct Incidental medical and dental training for all staff by POC date 04/25/2023. Staff agrees to email training documents to LPA Martinez by POC date 04/25/2023 5 PM.
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evidence by: based on observation and file review the facility did not ensure all of R1's medications were recorded on their Medication Administration Record (MAR). This posed a potential health and safety risk for 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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/12/2023 08:30 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 AC/SC, 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited

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1569.2 (p) Definitions: Residential care facility for the elderly” means a housing arrangement chosen voluntarily by persons 60 years of age or over...This requirement was not met as evidence by.
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staff agrees to not accept any another individual under the age of 60. Staff is in the process of evicting R5 31 year old Alta client due to higher level of care requirement. Staff agrees to review all residents assessment and determine residents compatibility by 04/25/2023.
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Based on file review and obsevation there are 4 residents under the age of 60, and all have diffrent levels of careThis posed a potential health and safety risk to residents in care.
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staff agrees to review age census regulations and email LPA Martinez residents assessments and a statement that he reviewed 1569.2 regulations by POC date 04/25/2023 by 5 pm.
Type B
04/25/2023
Section Cited

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87303 (e)(2) Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F
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staff agrees to reduce water heater temperature today. The Licensee agrees to email LPA Martinez water temperature logs starting 04/11/2023 to 04/25/2023. Water temperature log is due by POC Date 04/25/2023 by 5 PM.
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This requirement was not met as evidence by: based on observation and inspection the resident bathroom sink water temperature measured at 144 degrees. LPA Lee inspected the water, and it was too hot touch. This posed a potential health and safety risk to residents in care.
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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: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3