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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001322
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:43:10 PM


Document Has Been Signed on 09/12/2024 01:43 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:LOVE & CARE FOR ELDERFACILITY NUMBER:
347001322
ADMINISTRATOR:SUIUGAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:7931 COOK RIOLO ROADTELEPHONE:
(916) 723-2912
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Elizabeth SuiuganTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/12/24 to conduct the annual inspection. LPA met with Administrator, Elizabeth Suiugan and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of two (2) residents comparing with physician orders . LPA reviewed two (2) residents files. Deficiencies were observed during residents files review as listed on 809-D.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 116 degrees F, which is within the regulation range of 105-120 degree.

Following issues were observed during today's visit: Medications Management, Staff's Training Requirements, and citations were issued as listed on LIC809-D.

LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 09/30/24.
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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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 09/12/2024 01:43 PM - 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: LOVE & CARE FOR ELDER
FACILITY NUMBER: 347001322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff interview, staff, S2 does not have annual training records on file per requirement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Administrator shall ensure that all staff have required annual training per this Regulation and keep records for Departmental review. All POC documents are due by POC date- 10/11/24.
Type B
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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Based on staff's interview and record review for residents, R1 and R2, LPA found multiple issues including not having updated medication list, Centrally Stored Log with incorrect information, Incorrect Medications containers information, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Administrator shall send a letter of understading of this Regulation and will do monthly staff training for medication management till November 2024 and send proof to LPA every month. Furthermore, facility will ensure that all residents medications are given per thier physician's orders. All POC documents are due by 10/11/24.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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