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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 01:46:11 PM


Document Has Been Signed on 09/12/2024 01:46 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:Case Management - Annual ContinuationUNANNOUNCEDTIME 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 visit , LPA found out that staff, S1 was working at the facility without fingerprint clearance and not associated with facility. Deficiency was observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Immediate civil penalty of $500.00 were assessed today due to S1 working at facility without fingerprint clearance.

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 01:46 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
873355(e)

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Criminal Record Clearance. (e )All individuals subject to a criminal record review …shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ...This requirement was not met as evidenced by;
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Administrator agrees to submit a statement of understanding regarding fingerprint clearance needed before staff are able to begin working at the facility. All POC documents are due by 09/13/24.
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Based on staff's interview and record review, it was found that staff, S1 was working at the facility without fingerprint clearance which poses a immediate health and safety risks to residents in care.
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Immediate civil penalty of $500.00 were assessed today due to S1 working at facility without fingerprint clearance.

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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: 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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