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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801584
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:33:08 PM


Document Has Been Signed on 11/17/2023 03:33 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:LOVELY BOARD & CARE HOMEFACILITY NUMBER:
486801584
ADMINISTRATOR:ALMOGELA, ZENAIDAFACILITY TYPE:
740
ADDRESS:172 ZINNIA CIRCLETELEPHONE:
(707) 552-2077
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Zenaida AlmogelaLovely TIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Angelita Rebujio (S1), and toured the entire inside and outside with S1. Administrator/Licensee, Zenaida Almogela, was then called and arrived a few minutes later. There are currently 4 residents in care and they receive services from North Bay Regional Center (NBRC). This facility is licensed for 6 non-ambulatory residents, no approval for bedridden.

LPA toured facility and grounds and observed all required signs posted in common areas. Infection control practices are present. Facility has a 30-day supply of PPE. Facility has also submitted their Infection Control plan, which is a part of their Plan of Operation.
Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was fully charged, and have proof of being serviced on 1/16/2023. Smoke detectors and carbon monoxide detectors were tested and operational. Fire drills are conducted and the last one was documented on 10/10/2023. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars. The outside grounds have plants, fruit trees, and provide easy access for the residents to enjoy fresh air.

Resident and staff files are located and locked in closet. LPA reviewed resident files and were found complete and organized. Staff files were complete, organized, with proof of required annual training and CPR/1st Aid certificates expiring 4/19/2025.


Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVELY BOARD & CARE HOME
FACILITY NUMBER: 486801584
VISIT DATE: 11/17/2023
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Administrator certificate for Gaylord Almogela # 6014716740 expires 3/22/2024.

LPA discussed Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit copies of the below documents by 12/17/2023.



· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-
Copy of Administrator Certificate


No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2