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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202730
Report Date: 04/19/2024
Date Signed: 04/19/2024 01:31:34 PM

Document Has Been Signed on 04/19/2024 01:31 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LOVEWAYS CARE HOMEFACILITY NUMBER:
435202730
ADMINISTRATOR/
DIRECTOR:		RIZEL DUMONFACILITY TYPE:
735
ADDRESS:3601 EMMANUEL CTTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: DATE:
04/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator Rizel DumonTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management deficiencies visit due to violations discovered during the change of ambulatory status request process. LPA met with Administrator (ADM) Rizel Dumon.

On January 12, 2024, the department received a request for a change an increase in non-ambulatory status for the facility. (The facility had a fire clearance for 4 ambulatory and 2 non-ambulatory.) The facility was requesting for an increase in non-ambulatory to accommodate R1, who had a change in condition.

On January 29, 2024, the Department received an incident report, which was written on January 26, 2024. The incident report stated R1 had been transported back to the facility.

On April 19, 2024, LPA Monter interviewed ADM. ADM confirmed R1 moved back to the home on January 26, 2024.

The facility had accepted R1, prior to fire clearance, change of non ambulatory status had been approved.

A deficiency is being cited during todays visit, see LIC809-D. This report was reviewed with Administrator Rizel Dumon. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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 04/19/2024 01:31 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/19/2024 at 01:16 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LOVEWAYS CARE HOME
FACILITY NUMBER: 435202730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
80020(a)

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80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department... the State Fire Marshal.

This requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter by POC date.
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Based on interviews conducted, and records reviewed, the facility admitted a non-ambulatory resident, exceeding the facility's non-ambulatory capacity. This poses/posed a potential health, safety or 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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