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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412237
Report Date: 10/28/2022
Date Signed: 10/28/2022 01:53:12 PM

Document Has Been Signed on 10/28/2022 01:53 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:LOVING CARE RANCHFACILITY NUMBER:
366412237
ADMINISTRATOR:TERESA G. DATUINFACILITY TYPE:
740
ADDRESS:25445 NATIONAL TRAIL HWYTELEPHONE:
(760) 245-4523
CITY:HELENDALESTATE: CAZIP CODE:
92342
CAPACITY: 18CENSUS: 15DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Teresa Datuin, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA arrived and met with caregiver Anelit Mayores and explained the purpose of the visit. LPA was asked to sign-in upon arrival. The administrator Teresa Datuin was called by Mayores and Datuin arrived at the facility at 10:45 a.m.

During the inspection, LPA conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. The facility has three (3) separate building also referred to as ranch 1, ranch 2, and ranch 3 by staff. The facility has five (5) clients in care in ranch 1, nine (9) clients in care in ranch 2, and one (1) client in care in ranch 3. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed facility staff wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. LPA reviewed staff and clients records.

LPA was greet by an individual that was volunteering at the facility without the criminal records clearance. Per volunteer # 1 (V1), V1 is a neighbor and retired nursing assistant who has been helping out at the facility since COVID-19 and offered to assist LPA during today's inspection. LPA interview with the administrator revealed that V1 does maintenance around the facility but provides no patient care.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/28/2022 01:53 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/28/2022 at 12:32 PM
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: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring V1 had a criminal record clearance prior to volunteering at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2022
Plan of Correction
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The licensee shall ensure that V1 requests a live scan (LIC9163). The Licensee is advised that this individual cannot volunteer or reside at the facility until he/she has a criminal record clearance . Proof of the live scan shall be submitted to the regional office (RO) by 10/29/2022. A civil penalty of $500.00 has been assesse
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


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Document Has Been Signed on 10/28/2022 01:53 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/28/2022 at 12:32 PM
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: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, file review, the licensee did not comply with the section cited above in ensuring to obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year for C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee shall obtain and keep on file, documentation of a medial assessment signed by a physician, made within the last year for C2. Proof of correction shall be submitted to the regional office (RO) by 11/28/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


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Document Has Been Signed on 10/28/2022 01:53 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/28/2022 at 12:41 PM
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: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in ensuring adequate care and supervision for clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2022
Plan of Correction
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Licensee shall ensure that C1 will stay at ranch 1 during the day and put him outside when he wants to smoke. Licensee shall ensure that when C1 wants to lay down because there is no additional beds in ranch 1 that staff will be with him in ranch 3 so C1 can lay down. Licensee shall submit plan in writing to RO by 10/29/2022.

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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


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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: LOVING CARE RANCH
FACILITY NUMBER: 366412237
VISIT DATE: 10/28/2022
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LPA observed client # 1 (C1) in ranch 3 with no care providers. LPA interview with staff # 1 (S1) revealed that C1 is the only client in ranch 3. S1 states that there is staff staying in ranch 3 with C1 at night but no one there during the time of our tour, as all other staff were in the other two (2) building. Per S1, ranch 3 does not have an call system to hear the client while staff are away; however, facility staff checks on C1 every 30 minutes

LPA also observed during facility file reviews, that C2 has not had a documentation of a medical assessment, signed by a physician, made within the last year.

A civil penalty in the amount of $500.00 has been assessed for V1 volunteering without a criminal records clearance.

Based on observations made during today’s inspection, three (3) deficiency were cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted and a copy of this report, LIC 809D, LIC421BG, and Appeal Rights were given to the Administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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