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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 07/06/2023
Date Signed: 07/06/2023 05:22:39 PM

Document Has Been Signed on 07/06/2023 05:22 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:
07/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Karen LimTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to conduct a case management visit regarding a deficiency LPA observed. LPA met with staff, Carlo Mariano and Jane Merel, and explained the purpose of the visit. LPA asked staff to contact Administrator, Karen Lim, who arrived to the facility shortly afterwards.

LPA and Administrator discussed the importance of staff having criminal background clearance and/or transfer prior to working at the facility. LPA reminded Administrator it is a $100 civil penalty per day per staff, up to five days maximum. Additionally, LPA redirected Administrator to PIN 23-04 ASC released on February 13, 2023 for additional information on Guardian.

LPA informed Administrator transfer request can be submitted to CCLD via email and/or fax with the required documents of LIC 9182, ID card, and LIC 508.

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

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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 2
Document Has Been Signed on 07/06/2023 05:22 PM - It Cannot Be Edited


Created By: Cassie Yang On 07/06/2023 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement is not met as evidenced by:
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-S1 is to immediately leave the facility.
-S1 is to not return to the facility until S1 obtain a criminal record clearance.
-Licensee is to conduct a training with Administrator regarding fingerprint clearance prior to employment.
-Licensee is to submit a summary of the training to LPA Yang by 5:00 PM July 7, 2023.
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Based on records review and interview, Licensee did not comply as LPA observed S1 working, who is not associated to the facility on Guardian. Additionally, LPA was informed S1 has been working at the facility "off and on since June" which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
07/07/2023
Section Cited
CCR87411(g)(2)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
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-Licensee completed LIC 9182 and LPA will transfer S2 to the facility.
-Licensee is to conduct a training with Administrator regarding fingerprint clearance prior to employment.
-Licensee is to submit a summary of the training to LPA Yang by 5:00 PM July 7, 2023.
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Based on records review and interview, Licensee did not comply as LPA observed S2 working, who is not associated to the facility on Guardian. Additionally, LPA was informed S2 has been working at the facility for approximately "5 months" which poses/posed an immediate health, safety or personal rights risk to persons 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 Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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