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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:54:50 PM


Document Has Been Signed on 10/11/2023 12:54 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 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:
10/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Karen LimTIME COMPLETED:
01:05 PM
NARRATIVE
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On 10/11/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a post-licensing inspection. LPAs met with Administrator, Karen Lim, and explained the purpose of the visit.

LPAs conducted a tour with Administrator. In areas toured included but not limited to: staff room, 4 residents rooms, resident bathroom, staff bathroom, laundry room, kitchen, storage shed, backyard and common areas. At 11 A.M. LPAs and Administrator observed Oxy Clean cleaning supply located on the shelf in the residents bathroom. Additionally, LPAs observed Lysol cleaning spray located on dresser in a vacant resident room. LPAs observed two carbon monoxide detector in the facility, one near the front door and one near the kitchen. LPAs advised Administrator to change the carbon monoxide detector by the door as it was not working.

LPAs observed the sharps and medication to be stored in locked cabinets. The facility had 2 days of perishable and 7 days of nonperishable foods. LPAs observed Administrator Certificate #6063015740 to be current, expiration date of 05/31/2024. LPAs conducted a file review of one resident record and one staff record. LPAs observed staff record to have the required documents but documents were incomplete.

LPAs and Administrator discussed the topic of change of ownership, Administrator informed LPAs an intent to change ownership will be provided to LPAs and responsible parties.

As a result of today's inspection, deficiencies observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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 5


Document Has Been Signed on 10/11/2023 12:54 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 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: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPAs observed Oxy Clean cleaning spray located in the resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
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Licensee is to submit a compliance plan of how cleaning supplies will be stored after use, POC is due to LPA Yang by 10/12/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 10/11/2023 12:54 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 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: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPAs observed S1 to have a blank LIC503 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee is to submit a copy LIC 503's of all staff to LPA Yang via email by October 27, 2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5