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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803570
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:07:04 PM


Document Has Been Signed on 04/26/2022 04:07 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:LOVING PLACEFACILITY NUMBER:
486803570
ADMINISTRATOR:RAJWANT MINHASFACILITY TYPE:
740
ADDRESS:2429 HANCOCK DRIVETELEPHONE:
(707) 628-4451
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maureen Canizares, Lead caregiver TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with lead staff Maureen Canizares. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility and observed 4 residents in care. Facility has a screening station with sign-in sheet and COVID questionnaire. Staff have CPR/first aid certifications. Fire extinguisher was charged and serviced 03/30/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff have received and documented training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and Resident's temperatures are taken daily and documented. Caregiver Maureen stated staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Administrator stated over the phone that N-95 mask fit testing for staff (Cal/OSHA requirement) is in process.
The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed the following requirements with caregiver:
· Document verification of COVID Vaccination status or proof of negative COVID-19 test for indoor visitation

LPA requested the following updated records to be submitted to Community Care Licensing by 5/23/2022
    · LIC 308 Designation of Facility Responsibility
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate not handling cash for residents)
    · Copy of liability insurance
    · LIC 610E Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Lead Caregiver Maureen Canizares, whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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