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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 08/30/2023
Date Signed: 08/30/2023 01:29:15 PM

Document Has Been Signed on 08/30/2023 01:29 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:
08/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Carlo MarianoTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to the facility to ensure the health and safety of residents in care. LPA met with Caregivers Tim Baquerfo, Carlo Mariano, and Mae Castaneda and explained the purpose of the visit.

Note that at time beginning of visit, census was four (4). At time of concluding report, census is three (3) as one resident passed away. LPA observed family members and hospice was contacted. LPA spoke with residents (R1 and R2) family members.

LPA observed Caregiver Manuel Lasap arriving to the facility to collect payroll payments.

LPA observed the facility to have adequate 2+ days of perishable foods present in the refrigerator. LPA was informed by staff that food is starting to run low but caregiver will grocery shop once his shift was over.

LPA conducted a resident file review and was unable to find 3 out of 4 residents file. LPA was only able to locate R3's file. LPA was informed staff had previously asked for residents files but was informed "she said she'll take care of it". Additionally when asked why files are not safeguard, LPA was informed Licensee said a file cabinet was ordered already from Home Deport. Staff informed LPA this conversation occurred July 20th.

Additionally, LPA conducted a personnel file review and was provided a list of caregivers who works at the facility. LPA identified two staff working month of August 2023 who are not associated to the facility. LPA was informed S1 started working this month as a filled-in/on-call staff. LPA was informed S2 has been working as a full-on staff for a "couple of months".

Please continue on LIC 809-C...
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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Document Has Been Signed on 08/30/2023 01:29 PM - It Cannot Be Edited


Created By: Cassie Yang On 08/30/2023 at 12:36 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: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited

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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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Based on records review and interview, Licensee did not comply as LPA observed S1 and S2 to be scheduled at the facility, but not associated to the facility via Guardian. Additionally, when asked if Licensee knew that S1 was not associated, Licensee replied "Yes Ms. Cassie." which poses an immediate health and safety risk for residents in care.
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This is a civil penalty of $100 per day up to 5 days per staff. Additionally, a $250 repeated violation civil penalty will be assessed.
Type B
09/01/2023
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Based on observation and intevriew, Licensee did not comply as LPA observed only one out of four residents in care to have a file at the facility, which poses a potential health and safety risk for residents 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: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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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
VISIT DATE: 08/30/2023
NARRATIVE
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LIC 809-C...

LPA texted Licensee, Karen Lim, who confirm she was aware S1 is not associated. LPA asked Licensee if Designee of Responsibility, Oliver Fule, is able to complete LIC 9182 in Licensee's behalf, Licensee agreed. Note this is a repeated violation as facility was recently cited on 07/06/2023.

Shortly afterwards, Designee of Responsibility arrived to the facility and completed the LIC 9182 with LPA. Staff created a copy for the facility files and LPA.

As a result of today's visit, deficiencies are observed. Please see the attached LIC 809-D.

Exit interview conducted and a copy of report and appeal rights was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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