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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:00:17 AM


Document Has Been Signed on 09/13/2023 11:00 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ONLY LOVE ELDERLY CARE HOMEFACILITY NUMBER:
345002979
ADMINISTRATOR:LIM, KARENFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRTELEPHONE:
(808) 228-0588
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 3DATE:
09/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen LimTIME COMPLETED:
11:10 AM
NARRATIVE
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On 9/13/2023, Licensing Program Analysts (LPAs) Cassie Yang and Kevin Mknelly arrived unannounced visit at the facility to conduct a case management visit. LPAs met with Licensee, Karen Lim, and explained the purpose of the visit.

LPAs and Licensee discussed the facility's current status with the Department. LPAs stated Licensee's Administrator Certificate and facility license is active and in good standing.

Additionally, LPAs and Licensee discussed the importance of being in compliance when documents are asked to be submitted in a timely manner.

During office meeting held on September 1, 2023 with Licensee, Licensing Program Manager (LPM) Laura Munoz requested written statements of operation plans for facility and other additional facilities Licensee is associated with as Licensee informed LPA Yang and LPM that Licensee is “overwhelmed” by multiple responsibilities. Additionally, during this office meeting, it was requested to submit LIC 500 by close of business.

Another office meeting was held on September 5, 2023 upon Licensee’s request, during this meeting LPA Yang provided Licensee a blank copy of the LIC 500 and a copy of California Code of Regulation: Reporting Requirement. LPA Yang requested LIC 624A, LIC 500 and operation statements to be submitted.

As a result of today’s visit, deficiencies were cited. Please see attached LIC 809-D.

Exit interview, a copy of the report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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 09/13/2023 11:00 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ONLY LOVE ELDERLY CARE HOME
FACILITY NUMBER: 345002979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)… (A) Death of any resident from any cause regardless of where the death occurred…This requirement is not met as evidenced by:
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-Licensee will submit LIC624A for R1 via email to LPA Yang by 3PM on September 14, 2023.
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Based on observation, Licensee did not comply to the section cited above as LPA witnessed R1 died during LPA’s visit on 8/30/2023 and had reminded Licensee on 9/1/2023 and 9/5/2023 to submit R1’s LIC 624A within seven days of occurrence which Licensee did not, which poses a potential risk for residents in care.
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Type B
09/14/2023
Section Cited
CCR87755(c)

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87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by:
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-Licensee is to submit a plan on how Licensee will comply with providing requested documents in a timely manner.
-Additionally, Licensee is to submit a plan regarding Licensee’s plans on facility operation specifically if Licensee plans to close, please provide due dates and/or deadline.
-The following plans above are to be submitted via email to LPA Yang by 3PM September 14, 2023.
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Based on observation, Licensee did not comply with the section cited above as LPA requested an updated LIC 500 to be submitted on 9/1/2023 but failed to do so. Additionally, LPA Yang requested for the document on 9/5/2023 and 9/7/2023, which poses a potential health and safety risk for 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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