<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803782
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:21:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LOVING HEARTS CARE HOMEFACILITY NUMBER:
486803782
ADMINISTRATOR:DEVERA, ROSEFACILITY TYPE:
740
ADDRESS:1400 ANDOVER CTTELEPHONE:
(707) 290-0614
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 6DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Caregiver, Vicenta BarnetTIME COMPLETED:
02:40 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 at Loving Hearts Care Home for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Caregiver, Vicenta Barnet. Caregiver granted access into the home.

LPA toured the facility with the Caregiver at 12:00 PM, and observed that the facility was at a comfortable temperature was well lit. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Medications were centrally stored and locked. Cleaning products and other toxins are located under the kitchen sink and in the laundry room that was locked and inaccessible to residents in care. Fire extinguisher was last charged on November 2020. However, during the tour of the kitchen at 12:00 PM, LPA observed the knives being left unlocked and accessible to residents in care (See LIC 809D- Photograph taken). In addition, LPA observed a video and audio device leading to Resident #5's bedroom that was installed by the facility itself in the kitchen by the five foot credenza at 12:00 PM (See LIC 809D-Photograph taken). LPA toured the backyard at 12:10 PM and observed a single bed blocking the exit ramp leading to the backyard and a single bed partially blocking the left side of the home leading to a ramp that leads to Resident #2's bedroom (See LIC 809D-Photograph taken).

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Staff have had all PPE training required. Staff have been N95 Fit tested.

Deficiencies were observed on July 30, 2021 during a facility tour, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed. Appeal rights were given. Exit interview was conducted and a copy of this report was signed and given to the Caregiver, Vicenta Barnet.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LOVING HEARTS CARE HOME
FACILITY NUMBER: 486803782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement was not met as evidenced by:


Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed that the kitchen knives were unlocked in a kitchen draw. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 07/30/2021
Plan of Correction
1
2
3
4
Caregiver locked the knives and immediately. LPA educated the Caregiver about locking knives that could pose a potential danger to residents in care. In addition, facility staff will have to undergo training on safeguarding dangerous items in the home and provide proof of that training by no later than August 6, 2021.
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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LOVING HEARTS CARE HOME
FACILITY NUMBER: 486803782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:

Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in 1 out of 6 residents in care had a video and audio monitor installed in Resident bedroom #5 of which the resident resides in. This does not allow for privacy and/or not a substitution for staff monitoring of a resident. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
1
2
3
4
LPA educated staff on Personal Rights and privacy. Facility took out video and audio monitor from Resident #5s bedroom. LPA recommended retraining on staff regarding Personal Rights by August 06, 2021.
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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LOVING HEARTS CARE HOME
FACILITY NUMBER: 486803782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observation and interview with Caregiver, the facility failed to be in conformity by blocking exit door in the staff room leading to the exit ramp to the backyard. The ramp itself was also blocked by a metal single bed that residents use. In addition, LPA also observed an exit ramp on the left side of the home being partially blocked by a blue single bed. This exit is for a resident and also leads to the backyard. This poses an immediate health and safety risk to residents in care. **Immediate Civil Penalty assessed in the amount of $500.
POC Due Date: 07/30/2021
Plan of Correction
1
2
3
4
Licensee to ensure walkways and exits are unobstructed. Licensee to review fire code regulations and submit self-certification that items blocking exits have been removed. Administrator shall provide proof of training on fire code regulations by August 6, 2021.
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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4