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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002717
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:01:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ONLY LOVE ELDERLY CARE HOMEFACILITY NUMBER:
347002717
ADMINISTRATOR:BUCOVATI, SHEILAFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRIVETELEPHONE:
(916) 488-0864
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Florin Bucovati, Co-Administrator TIME COMPLETED:
04:00 PM
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
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Loretta Cobourne and Nickay Ayton, caregivers. Co-Administrator, Florin Bucovati, arrived shortly to the facility and LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility currently has (5) residents and (0) residents are on hospice. LPA observed (5) residents to be in the front room watching television. Facility has (2) live-in caregiver staff.

LPA and Co-Administrator toured the interior of the facility. LPA observed it to be clean, in good repair and to be odor free. LPA observed various Covid posters throughout the facility and Department Provider Information Notice (PIN) to be available to review by entry. Rooms toured include (2)private bedrooms and (2) shared bedrooms, kitchen, laundry, staff room and common areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LP and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 73 F. Fire extinguisher last serviced 10/13/2021 and smoke/monoxide alarms are in working order, LPA observed sufficient 2+day perishable and 7+day non-perishable food and PPE supply. LPA observed paper towels, soap and sanitizer in the bathrooms. Sharps, toxins and medications are secured appropriately. LPA and Administrator discussed vaccination status of residents and staff and reviewed PIN 21-40 issued 8/27/2021 regarding visitation updates.made. All staff are cleared and associated to the facility.

LPA requested an updated copy of LIC308, current liability insurance and Administrator re-certification.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report to be e-mailed to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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 1