Community Care Licensing

Document Has Been Signed on 01/29/2025 03:31 PM - It Cannot Be Edited

FACILITY NAME:	ONLY LOVE ELDERLY CARE HOME		FACILITY NUMBER:	345002979
ADMINISTRATOR/ DIRECTOR:	ALEKSANDR SHELUDCHENKO		FACILITY TYPE:	740
ADDRESS:	4901 MELVIN DR		TELEPHONE:	(808) 228-0588
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 6		CENSUS: 4	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:55 AM
MET WITH:	Aleksandr Sheludchenko		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

SUPERVISORS NAME: Laura Munoz LICENSING EVALUATOR NAME: Cheyenne Ratajczak LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as LPA observed hydrogen peroxide in resident bathroom and it was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Staff stored hydrogen peroxide in a locked cabinet. Licensee to submit to LPA a statement of understanding of this regulation by POC due date.

Type A

Section Cited

CCR

87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff do not have fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	S1 is to leave the facility immediately. S2 may stay at the facility as it is S2s first day of training. S2 cannot provide clients with dressing, grooming, bathing or personal hygiene, cannot be left alone with clients in care, cannot spend more than 16 hours per week at the facility. Licensee to provide LPA with staff schedule and complete live scan for S2.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Cheyenne Ratajczak LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type B

Section Cited

CCR

87412(a)(11)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three (3) out of five (5) staff do not have a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee is to have LIC503 completed for all staff by POC due date. Once completed send to LPA.

Type B

Section Cited

HSC

1569.185(b)(1)(F)

§1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (b) (1) In addition to fees set forth in subdivision (a), the department shall charge all of the following fees: (F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above as LPA observed outstanding balance of $1,237 due to unpaid fee plus late fee assessed, which poses a potential health and safety risk for residents in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee is to pay annual fee and late fee by poc due date. Licensee to send LPA proof once completed.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Cheyenne Ratajczak LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four (4) out of five (5) staff do not have completed training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee is to conduct initial training for all staff. Proof of training must be placed in file. Licensee is to notify LPA when completed.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Cheyenne Ratajczak LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of four (4) resident files were incomplete with no admission agreement and pre admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee is to complete an admission agreement and appraisal for R1 and R2. Licensee to send proof to LPA once completed.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above facility did not conduct any drills in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee is to complete a emergency drill by POC due date. Once completed send in documentation to LPA.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Cheyenne Ratajczak LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

FACILITY NAME: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
	VISIT DATE: 01/29/2025