486803570-4-14-2025-21-AS-SSTN-DFQPZA-20250414114514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803570
Report Date: 04/11/2025
Date Signed: 04/14/2025 11:45:42 AM

Document Has Been Signed on 04/14/2025 11:45 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 PLACE		FACILITY NUMBER:	486803570
ADMINISTRATOR/ DIRECTOR:	RAJWANT MINHAS		FACILITY TYPE:	740
ADDRESS:	2429 HANCOCK DRIVE		TELEPHONE:	(707) 628-4451
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	04/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Licensee/Administrator Manjit Minhas		TIME VISIT/ INSPECTION COMPLETED:	01:05 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	Due to computer technical issues, a paper 809 and Administrator/Licensee signature is on file At approximately 09:45 am, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by Licensee/Administrator Manjit "Goldie" Minhas Facility is a Residential Care Facility for the Elderly (RCFE) licensed for 6 residents with five (4) residents in care. Facility has a Hospice waiver for Three (3), with 1 hospice residents currently in care, and is approved for six (6) non-ambulatory residents. At approximately 10:15 am, LPA initiated a tour of the facility with licensee and observed the following: Facility is a one story home with front of the house views of the hills, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 03/2025 and were observed to be fully charged . Water temperatures measured between 105F and 120F per title 22 Regulations LPAs observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a 2-day supply and variety of healthy perishable foods, 7-day supply of non-perishable food, and emergency water supplies. In addition, a variety of snacks and fruits were observed to be set out for residents. Food was found to be stored in a safe manner with open items covered. Continued on 809C

Kimberley Mota	TELEPHONE: (707) 588-5051
Star Stevenson	TELEPHONE: 707-588-5081
	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LOVING PLACE	FACILITY NUMBER: 486803570
	VISIT DATE: 04/11/2025

NARRATIVE

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Continued from 809...
Facility has an emergency whole-house backup battery wall. LPA observed TVs, books, patio with sun and shade Licensee was advised to ensure that tall green grasses were cut to reduce fire hazard as grasses dry out. Disaster drills were last conducted January 2025

At approximately 11:15 AM LPA conducted a review of four (4) staff records. All 4 staff had required criminal clearance, health records and educational training.
At approximately 11:45 AM LPA conducted review of four (4) resident records. Most required documentation was in place, except four (4) of four (4) did not have signed Consent for Emergency Medical Treatment (LIC627C) B-Deficiency issued and Plan of Correction (POC) developed with administrator and due by 05/16/2025

At approximately 12:30PM PM LPA and Licensee Minhas conducted a spot check of medication and medication records with records observed centrally stored and locked.

A copy of current Facility sketch was obtained today

Licensee/Administrator to submit updates of the following documents by 05/16/2025
LIC 500 Personnel Summary
Evidence of current liability insurance
LIC 308 Designation of facility responsibility.
LIC 610 Emergency Disaster Plan - updated (if needed) and signed and dated

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Licensee/Administrator Minhas Manjit and Appeal rights were given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Star Stevenson	TELEPHONE: 707-588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2025 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LOVING PLACE	FACILITY NUMBER: 486803570
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87468(b)(1)(A)

Personal Rights of Residents

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review the licensee did not comply with the section cited above in four (4) out of four (4) persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2025
	Plan of Correction
1 2 3 4	Licensee will submit signed and dated Consent for Emergency Medical Treatment (LIC627C) for all residents in care by Plan of Correction date 05/16/2025

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kimberley Mota	TELEPHONE: (707) 588-5051
Star Stevenson	TELEPHONE: 707-588-5081
	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC809 (FAS) - (06/04)

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