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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412237
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:13:14 AM

Document Has Been Signed on 11/02/2022 11:13 AM - 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:
11/02/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Anelit Mayores, CaregiverTIME COMPLETED:
11:16 AM
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On 11/02/2022 at 9:40 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a Plan of Correction (POC) visit to confirm that the citation issued on 10/28/2022 has been corrected. LPA arrived and met with Caregiver Anelit Mayores and explained the purpose of the visit. 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 2, nine (9) clients in care in ranch 1, and one (1) client in care in ranch 3.

On 10/28//2022, LPA Nickolas cited the following deficiency:
CCR 87411(a) Personnel Requirements for client # 1 (C1) left unattended in ranch 3.

During todays visit the deficiency was not corrected. A civil penalty for a repeat violation has been assessed in the amount of $250.00.

This report was discussed with the staff, and copies of this report, LIC 809D, LIC 421FC, and Appeal Rights were provided to Mayores.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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 11/02/2022 11:13 AM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 11/02/2022 at 10:29 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: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
87411(a)

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 87411(a) Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....

This requirement was not met as evidenced by:
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Licensee shall ensure that staff is present at all times in ranch 3 or install a call system. Licensee shall read CCR 87411(a) and submit a letter of understanding to the Regional Office (RO) by the POC due date.
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Based on observation and interview the licensee did not ensure that C1 was not left unattended or a call system was installed in ranch 3, which poses an immediate health, safety, or personal right risks to persons 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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
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