486803782-7-19-2024-21-AS-DTOA-D7BTVP-20240719150413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803782
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:08:31 PM

Document Has Been Signed on 07/19/2024 04:08 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:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Rose Devera Licensee & Administrator, Dinah Belandres,		TIME COMPLETED:	03:15 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 7/19/2024, Licensing Program Analyst (LPA's) Tobola & Loera conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Dinah Belandres. Licensee, Rose Devera was contacted and arrived later in the visit. The facility currently provides care for 6 residents, two of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility 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 Extinguishers found to be last charged on 11/9/2023 at the time of visit. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings. Staff provide residents with meals according to dietary restrictions with an ample amount of fresh and healthy foods observed. Cleaning supplies and other toxins are to be safely stored in locked cabinets in the laundry room and under kitchen sinks. Upon inspection LPA's observed a bottle of bleach located in resident restroom. Item was immediately removed and secured. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. A half rail was observed in resident (R1) bedroom without a proper physician's order. Administrator immediately removed bed rail and is to contact R1's physician for clearance. Technical Violation issued. Residents that were awake during the inspection were observed interacting with staff in the common area, in their bedroom watching television or resting. The facility encourages regular family visits and utilizes outdoor areas for resident exercise and mobility. There is emergency exit located in the backyard which was found to be unobstructed. There is an outdoor patio with shade and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. Administrator is to provide a device with internet access for residents. Administrator agrees to send photo proof of device to CCLD Technical Advisory issued. 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: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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 3

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: 07/19/2024

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
26
27
28
29
30
31
32

LPA's conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA's requested for Licensee to update dementia training to meet regulation. Technical Violation issued. All required positing and signeage at the front and hallway of the facility were found to be in order with information easily accessible for staff and residents. LPA's conducted a sample file review for residents and found all needs & service plans and physician's reports to be in order. Lastly, a spot medication check was conducted, medication supply and medication records were all found to be in order.

Administrator, Dinah Belandres's Administrator Certification 7032809740 is valid through 2/17/2025.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA requested the following documents be sent to CCL by COB 8/2/2024:

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/19/2024 04:08 PM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LOVING HEARTS CARE HOME	FACILITY NUMBER: 486803782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) 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 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 1 bottles of bleach found accessible in resident restroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Administrator immediately removed bleach from resident restroom and secured. Administrator understands to ensure all items that could pose a safety risk to residents in care are kept inaccessible to residents. Deficiency cleared at time of visit.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3