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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411418
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:24:53 PM

Document Has Been Signed on 12/19/2023 12:24 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:LOVE & CARE HOMEFACILITY NUMBER:
366411418
ADMINISTRATOR:DY, ZENAIDA G.FACILITY TYPE:
735
ADDRESS:5475 ARENA WAYTELEPHONE:
(909) 899-1061
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 2DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Licensee/Administrator Zenaida DyTIME COMPLETED:
12:30 PM
NARRATIVE
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On 12/19/2023 at 09:08 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required comprehensive annual visit to the facility. LPA Brown met with Licensee/Administrator Zenaida Dy introduced self, and stated the purpose of the visit.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, and attached garage. The facility is vendorized by Inland Regional Center. LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPA Brown observed no clients at the facility as they are out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 110 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LOVE & CARE HOME
FACILITY NUMBER: 366411418
VISIT DATE: 12/19/2023
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Yards/Outside: One shaded patio, one (1) side gate with door knob not lock on the right side of the house that leads into the backyard, and three (3) car attached garage observed. The outdoor pathway on the side of the facility was free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed two (2) client files for admission agreements and needs and services plans, functional capabilities and Physician Report (LIC602). LPA Brown observed that Client #1 (C1) and Client #2 (C2) do not have the Needs and Services Plan in their facility file and C1 does not have Functional Capabilities in C1 file. Deficiencies will be issued as this pose potential health, safety, and personal rights risks to clients in care. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings, no issues observed. LPA Brown reviewed C1 and C2 P&I records and LPA Brown observed no issue. LPA Brown reviewed C1 and C2 medications, LPA Brown observed no issue.

Two (2) deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Zenaida Dy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2023 12:24 PM - It Cannot Be Edited


Created By: Melody Brown On 12/19/2023 at 11:51 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LOVE & CARE HOME
FACILITY NUMBER: 366411418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing Client #1 (C1) Functional Capabilities form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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The Licensee stated to submit a copy of C1's completed Functional Capabilities form to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80068.2(a)
80068.2 Needs and Services (a) The Licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, or 85068.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above by not having a completed Needs and Services Plan for Client #1 (C1) and Client #2 (C2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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The Licensee stated to submit a copy of C1 and C2 completed Needs and Services Plan to LPA Brown at POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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