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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:34:25 PM


Document Has Been Signed on 02/23/2024 04:34 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: 4DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:AdministratorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with Administrator, Karen Lim, and explained the purpose of the visit.

Facility is licensed for six non-ambulatory residents and hospice waiver of three. Facility has census of four residents with three on hospice services which is compliance to licensure.

During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents rooms, bathrooms, laundry room, kitchen, backyard and the common areas. LPA observed the presence of four residents in care with two caregivers present. LPA observed medications to be locked and inaccessible to resident in care. LPA observed the exterior of the facility to be free from obstruction and/or blockage. LPA observed medications to be properly locked and inaccessible. LPA observed knife drawer to be locked.

LPA and Administrator discussed the assistance of technical support program. LPA was informed there was a video call today to discuss corrections. LPA and Administrator discussed changing facility sketch for all private rooms. LPA informed Administrator to submit LIC 200 and facility sketch of the following for clearance. Additionally, Administrator and LPA discussed steps to increase hospice waiver by submitting the request with the required criteria listed.

LPA completed the CARE tool with Administrator. No deficiencies cited.

Exit interview conducted and a copy of the report was provided to Administrator via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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