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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002717
Report Date: 12/30/2022
Date Signed: 12/30/2022 03:34:34 PM


Document Has Been Signed on 12/30/2022 03:34 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
CHICO - RESIDENTIAL, 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:
12/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Karen Orozco LimTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on 12/30/2022 to conduct a Required 1-year inspection. LPA met with Administrator, Karen, who informed LPA she is currently in the process of change of ownership. LPA inform the facility masking is still mandated for staff and visitors.

LPA and Administrator toured the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: common areas, resident private rooms, bathrooms, kitchen and laundry room. In areas toured, no immediate health and safety risk were observed. LPA observed the fire extinguisher to be last serviced on 11/1/2022. LPA observed the facility to have adequate PPEs, and linens. LPA observed sharps, toxics and medications to be locked and secure, inaccessible to residents.

LPA observed Administrator Certificate to be up to date with expiration of 5/31/2024. LPA reviewed the facility to have a hospice waiver of 1 but the facility currently has 5 residents with 3 on hospice services. LPA provided Administrator the printout of Title 22 Regulation 87632 which includes the criteria needed in the hospice increase request.

LPA obtained a copy of the Administrator Certification and liability insurance.

During today's inspection, deficiencies were observed. Please see attached LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was left with Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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 12/30/2022 03:34 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ONLY LOVE ELDERLY CARE HOME
FACILITY NUMBER: 347002717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited

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87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... This requirement is not met as evidenced by:
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The licensee shall submit required documents/request to the Department in order to obtain an additional hospice resident by 01/13/2023.
The licensee is advised that the facility may not retain the additional hospice resident if the request is denied.
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Based on interview, the licensee failed to obtain/maintain an appropriate hospice waiver. LPA observed the facility hospice waiver is for (1) resident, but the facility currently has (3) residents on hospice. This poses a potential health and safety risk to 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
LIC809 (FAS) - (06/04)
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