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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920294
Report Date: 05/14/2026
Date Signed: 05/14/2026 11:47:49 AM

Document Has Been Signed on 05/14/2026 11:47 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:LOVE & CARE FOR ELDER IIIFACILITY NUMBER:
345920294
ADMINISTRATOR/
DIRECTOR:		SUIUGAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:7991 COOK RIOLO RD.TELEPHONE:
(916) 412-7301
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 5DATE:
05/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Elizabeth SuiuganTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived on 5/14/26 to conduct the annual inspection. LPA and LPM met with Administrator, Elizabeth Suiugan who assisted during today's inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used.
LPM, LPA reviewed all five residents and two staff files. Medications review was conducted.

LPA, LPM and staff toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. LPA, LPM checked the kitchen area for the ability to prepare and store food. LPA, LPM observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher was serviced on 10/24/25 and was ready for emergency use.

LPA, LPM requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 5/31/26.

CONTINUED ON LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Talwinder Bains
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/14/2026 11:47 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/14/2026 at 10:38 AM
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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(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
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Based on observations, staff left knives and sharp objects in kitchen area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Licensee/Administrator shall send a letter of understanding, shall conduct all staff training on this regulation and send proof to department by POC date, 5/15/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/14/2026 11:47 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/14/2026 at 10:38 AM
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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, staff are bringing resident's to a neighboring facility without increase staffing. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Licensee/Administrator agreed to no longer bringing resident's at this home to a neighboring facility daily for meals. Additionally, if the licensee wishes to join resident's on occasion, the licensee shall submit a plan staffing for the activity. Lastly, licensee shall submit an updated LIC500 and send proof to department by POC date, 5/15/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/14/2026 11:47 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/14/2026 at 10:38 AM
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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review indicated that medications records were not properly maintained on Centrally Stored Logs, updated medications lists were not present in residents files, staff were writing instructions on medications bottles and facility was not disposing discontinued medications per requirements, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Licensee/Administrator agree to obtain updated medication lists for all resident and conduct a medication audit with medication list to ensure all medications being administered are correct. Any discontinued medications will be documented as required. Additionally, the licensee shall submit a plan on how the facility will maintain medications and medication records ongoing. Licensee shall send proof to department by POC date, 5/15/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/14/2026 11:47 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/14/2026 at 10:38 AM
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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review indicated that , Staff, S2 file was missing CPR/First Aid certificate, LIC501,LIC503, LIC508, TB test, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
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Licensee/Administrator shall send a letter of understanding , ensure all above cited issues were corrected for all staff's files and send proof to department by POC date, 5/28/26.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review for residents, R1,R3,R5 indicated that documents were present but were incomplete and/or not signed and/or dated by staff and/or resident/family as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
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Licensee/Administrator shall send a letter of understanding , ensure all above cited issues were corrected for all residents files and send proof to department by POC date, 5/28/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/14/2026 11:47 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/14/2026 at 10:38 AM
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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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Based on record review , it was noted that facility was not conducting quarterly fire and disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
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Licensee/Administrator shall send a letter of understanding, shall conduct quarterly fire and disaster drills as required and send proof to department by POC date, 5/28/26.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


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: LOVE & CARE FOR ELDER III
FACILITY NUMBER: 345920294
VISIT DATE: 05/14/2026
NARRATIVE
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Upon arriving to the facility, LPA and LPM found no resident's in the facility. Staff, Rabecca Szabo indicated all the resident's from this home (5 residents) go across the street to another facility licensed by the licensee. LPA and LPM went to the other licensed home and found 9 resident's sitting at a dining table finishing breakfast. Only one staff was present in the home at that time. When asked how resident's were transported, staff indicated one staff will walk each resident across the street to the other home, leaving the other resident's unattended outside waiting to be brought over. LPM advised the licensee and staff that bringing resident's from home to another is a health and safety risk. Based on Title 22 regulations, resident's need to be supervised at all times. Additionally, resident's have the right to refuse leaving the facility and it is unclear if resident's are given the right to stay at this home. Lastly, bringing resident's from one home to another violates the fire clearance allotment. The licensee indicated that meals would be served to resident's at the homes they reside at and that on occasion when resident's are brought together, the facility will ensure will have sufficient staffing at all times.

During medication audit, the facility does not have an organized system of tracking and maintaining resident's medications. The Department has advised the licensee that a referral to the Technical Support Program (TSP) will be submitted.

Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

Exit interview conducted. Copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Talwinder Bains
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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