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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803570
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:59:23 PM


Document Has Been Signed on 03/27/2023 01:59 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: 3DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rajwant (Goldie) Minhas, AdministratorTIME COMPLETED:
02:11 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rajwant (Goldie) Minhas, Administrator.
LPA toured the facility and observed all exits were unobstructed. Fire extinguisher was charged and serviced 03/30/2022. 7 combination smoke and carbon monoxide detectors were tested and observed operational. LPA reviewed staff and resident files. Staff have cardiopulmonary resuscitation (CPR) and first aid training completed. LPA observed resident medication to be centrally stored. Bedrooms were furnished per regulation. The facility was found to be clean and at a comfortable temperature. LPA observed hygiene supplies and hand soap available in bathrooms. Food supply was within regulation. All staff wore masks during this visit.
LPA discussed the following regulations and advisory notes with Administrator: 87465(h)(5); 87463(a); 87219(a)(1); 87468(c)(2)(A)

LPA requested the following updated forms to be submitted to Community Care Licensing by 04/27/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if 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

Exit interview conducted with Rajwant (Goldie) Minhas, Administrator, whose signature on this document confirms receipt.
*** No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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