<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:19:38 AM


Document Has Been Signed on 09/01/2023 11:19 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:
09/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen LimTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An informal office meeting was conducted on September 1, 2023 with Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100. Present in the meeting was Administrator/Licensee, Karen Lim, Property owner, Antolin Gonzales, Regional Manager (RM), Alycia Berryman, Licensing Program Manager (LPM), Laura Munoz, and Licensing Program Analyst (LPA), Cassie Yang.

The purpose of this informal office meeting is to address the Department's concerns of facility's financial distress, staffing concerns and background criminal clearance.

The following topics were covered during today's meeting:
  • False claims regarding designation of Administrative Responsibility
  • False claims regarding missing staff wage
  • False claims regarding rent payment
  • Staff Background Criminal Clearance
  • Licensee's association and/or role with other RCFE's

Licensee agreed to do the following:
  • Submit proof of staff wage payment by today, September 1, 2023 at 5 PM.
  • Submit LIC 500 by today, September 1, 2023 at 5 PM.
  • Submit statement reassigning Licensee's Administrative roles to other designees by today, September 1, 2023 at 5 PM.

As a result of today's meeting, deficiencies were cited. Please see LIC 809-D

An exit interview was conducted and copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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 09/01/2023 11:19 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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87207

1
2
3
4
5
6
7
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to submit proof that all staff wage has been paid. Submit proof to LPA Yang by September 1, 2023 by 5 PM.
8
9
10
11
12
13
14
Based on interview, Licensee did not comply as Licensee reported to LPA that rent payments are up to date and "resolved". Additionally, Licensee informed LPA all staff wage has been paid, but date of meeting, Licensee admit there are two staff who are still not paid, which poses an immediate health and safety risk for residents in care.
8
9
10
11
12
13
14
Type B
09/01/2023
Section Cited
CCR87405(a)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to ensure designated Administrator is informed of role prior to Administrator's absence.
Licensee is to appoint a new Administrator and submit the required documents to corresponding LPA by September 1, 2023 at 5 PM.
8
9
10
11
12
13
14
Based on observation and interview, Licensee did not ensure a designee Administrator was assigned as Licensee designated S1 to be Administrator but when LPA contacted S1, S1 stated she does not work at the facility, which poses a potential risk for residents in care.
8
9
10
11
12
13
14
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: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2