486803436-10-10-2023-21-AS-FSAI-CWGQGD-20231010120922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803436
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:09:39 PM

Document Has Been Signed on 10/10/2023 12:09 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:	SAFE & LOVING SENIOR CARE		FACILITY NUMBER:	486803436
ADMINISTRATOR:	JOSEPH, LOVELY		FACILITY TYPE:	740
ADDRESS:	1647 VANDENBERG CIRCLE		TELEPHONE:	(707) 384-3911
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	4	CENSUS: 1	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee, Lovely Joseph		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Safe & Loving Senior Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee, Lovely Joseph and was granted access into the facility. LPA and Licensee toured the one story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on September 2022 at the time of the inspection. Licensee disclosed that there is an upcoming appointment to have the Fire Extinguisher serviced tomorrow, October 11, 2023 (See LIC 9102-Technical Violation). Proof was provided via a telephone call to the Fire Extinguisher company that handles inspecting and refilling Fire Extinguishers. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in residents bathroom measured at 116 degrees, within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of a resident bedroom was conducted, bedroom inspected have lighting and appropriate furnishing. LPA discussed the Infection Control Plan with the Licensee and advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. (Report continued on LIC 809C). LPA discussed the Emergency Disaster Plan with the Licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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: SAFE & LOVING SENIOR CARE	FACILITY NUMBER: 486803436
	VISIT DATE: 10/10/2023

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During the Required 1 year inspection, LPA reviewed 2 of 2 staff files. 1 of 2 staff files were found to be needing more training (See LIC 9102-Technical Violation). LPA reviewed the Medication Orders and found those to be appropriate during the inspection. LPA reviewed 1 of 1 resident records and found those to be appropriate during the inspection. LPAs interviewed 1 of 1 residents in care. During staff record review, LPA found that both First Aid/CPR certificates have expired for the Licensee and the Caregiver. Both the Licensee and the Caregiver are registered to receive First Aid/CPR Card training this week (See LIC 9102-Technical Violation). Proof was provided to the LPA regarding registration for First Aid/CPR card training. LPA interviewed 1 of 1 caregivers.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
Updated facility sketch
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Licensee

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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