486803782-8-3-2023-21-AS-DTOA-CUCRU6-20230803131925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803782
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:19:28 PM

Document Has Been Signed on 08/03/2023 01:19 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 HEARTS CARE HOME		FACILITY NUMBER:	486803782
ADMINISTRATOR:	DEVERA, ROSE		FACILITY TYPE:	740
ADDRESS:	1400 ANDOVER CT		TELEPHONE:	(707) 290-0614
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Rose Devera, Licensee		TIME COMPLETED:	01:30 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	On 8/3/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Staff, Frank Oboza . Administrator, Dinah Belandres and Licensee Rose Devera were contacted and arrived later in the visit. The facility is a single story home licensed for six non-ambulatory residents and a hospice waiver capacity of 3. The facility currently provides care for 6 residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Lead staff; Frank Oboza and Licensee, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/7/2022 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were also tested and found to be functioning. Smoke detectors were also observed to be interconnected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room and under kitchen sink both of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen cabinet. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 116.6 and 119.1 degrees F which is within regulation. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: LOVING HEARTS CARE HOME	FACILITY NUMBER: 486803782
	VISIT DATE: 08/03/2023

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Medications located in designated closet located in the kitchen were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Facility and resident responsible parties are responsible for picking up medications and keep track of refills ensuring orders are placed around the final 5-10 doses of prescribed medications. Resident were observed interacting with staff in the common area, watching game show television or interacting with staff for leisure. There is one emergency exit located in the backyard which was found to be unobstructed. All auditory alarms leading out of the facility including resident bedroom emergency exits were tested and all found to be in working order.

LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found that all resident Needs & Service Plans have been updated as of July 2023 but require signatures from resident responsible parties. Licensee agrees to contact resident responsible parties for signatures. Technical Advisory issued. During the tour of the facility, LPA observed the window screen and blinds located in resident's (R1) bedroom #3 in need of repair or replacement. Technical Violation issued. Licensee immediately contacted the facility maintenance staff who measured and immediately replaced the items during the time of visit.

Licensee, Rose Devra's Administrator Certification 6008400740 is valid through 11/1/2024.
Administrator, Dinah Belandres's Administer Certification is currently pending. LPA confirmed that the re-certification training and payments were received by the department as of 2/10/2023.

LPA requested the following documents be sent to CCL by COB 9/3/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property/Rental Agreement

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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