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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803436
Report Date: 08/20/2021
Date Signed: 09/02/2021 11:34:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SAFE & LOVING SENIOR CAREFACILITY NUMBER:
486803436
ADMINISTRATOR:JOSEPH, LOVELYFACILITY TYPE:
740
ADDRESS:1647 VANDENBERG CIRCLETELEPHONE:
(707) 384-3911
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:4CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Lovely Joseph, AdminsitratorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA), Katrina Walters arrived at Safe & Loving Care Facility for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Lovely Joseph(LJ) # 6016407740 exp 5/31/2022. There were no resident in care at the time of inspection. LPA explained that this visit will be focused on this facility preparedness for Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA conducted a walk-through of the facility with the Administrator. The Administrator has prepared for infection control by saving a 30-day supply of Personal Protective Equipment (PPE), 30-day supply of emergency food and incontinence care supplies for all residents. Facility has a designated visitation area. LPA Walters and Administrator discussed how to prepare the facility for COVID-19 preparedness, when residents are in care.
Prior to accepting residents, the Administrator will make the following updates:

Create a sign in policy with COVID-19 screening questions.
Post signs throughout the facility to promote hand washing and social distancing.
Develop procedures for surveillance testing staff.
Conduct infection control training.

LPA is requesting copies of the following updated forms be submitted to CCL by 8/31/2020:
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 610E- Emergency Disaster Plan
LIC 808 Facilities Mitigation Plan
Copy of Current Administrator's Certificate & Surety Bond
No Deficiencies cited during today's inspection

*This is a copy of the original report. The original report was lost due to technical issues. A copy of the original report with signature will remain on file.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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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