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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603788
Report Date: 09/01/2022
Date Signed: 09/01/2022 12:25:58 PM


Document Has Been Signed on 09/01/2022 12:25 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LOVING HANDS SENIOR CAREFACILITY NUMBER:
374603788
ADMINISTRATOR:WILDFONG, MARIAFACILITY TYPE:
740
ADDRESS:3245 STAR ACRES DRIVETELEPHONE:
(619) 303-3862
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY:6CENSUS: 2DATE:
09/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Administrator, Maria WildfongTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renita Hall and Interim Assistant Program Administrator (IAPA) Icela Estrada conducted a case management visit to discuss deficiencies observed during a complaint investigation visit conducted on this date. Upon entry, LPA and IAPA identified themselves to staff Martha Corona and Linda Ibisate and met with and discussed the purpose of the visit. During the visit, Administrator Maria Wildfong arrived and the purpose of the visit as discussed with her as well.

During a complaint investigation visit, IAPA and LPA observed two staff not wearing a face mask. When Administrator arrived, she also was in the facility for a period of time without wearing a face mask. The importance of employees wearing face masks while in the facility was discussed with the Administrator and IAPA conveyed that as of today, guidance has not changed.

During interview with Administrator and review of a hand written schedule of staff, it was noted that staff #1 (S1) has been providing assistance with care and supervision since approximately since June 2022. A check of CCLD systems revealed that S#1 is not associated to this facility and Administrator advised she has not started the process to get her background cleared.

Per Title 22 of the California Code of Regulations, the following deficiencies are cited and listed on form LIC 809-D. An immediate civil penalty of $500 was assessed today for Criminal Record Clearance violation on form LIC 421-BG.

An exit interview was conducted with Administrator Maria Wildfong. A copy of this report, LIC 421-BG, and Licensee's Appeal Rights were provided to the Administrator via electronic mail during the visit due to printer issues.. An e-mail read receipt confirms the receipt of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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 09/01/2022 12:25 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374603788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited

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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 CA clearance or a criminal record exemption as required by the Department.
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This requirement was not met as evidenced by: Based on interview, records, and systems review, the licensee did not ensure Staff #1 had a CA criminal record clearance prior to working or volunteering in the licensed facility which posed an immediate safety risk to 2 of 2 residents in care.
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Type B
09/15/2022
Section Cited

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Personal Rights of Residents in All Facilities
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observations, the licensee did not accord healthful accommodations in 2 of 2 persons in care
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which posed a potential health and personal rights risk 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: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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