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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803570
Report Date: 04/19/2024
Date Signed: 04/19/2024 11:53:56 AM


Document Has Been Signed on 04/19/2024 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rajwant (Goldie) Minhas, AdministratorTIME COMPLETED:
12:00 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for five non-ambulatory and one bedridden resident. There are four private resident rooms and one shared resident room. There are two caregiver rooms. There is a laundry room. The resident rooms and common areas were toured and no issues found.

Two staff files and two resident files were reviewed.

The following was observed during today's visit:
-the facility sketch submitted to Community Care Licensing Division with the application in 2014, does not match the floor plan. It does not have one of the staff rooms, has an extra staff room, and the layout appears to be flipped. LPA discussed the facility sketch with Co-Licensee Manjit Minhas and he stated he will submit a new one.

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 15, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-facility sketch

no deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
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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