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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 11/16/2020
Date Signed: 04/22/2021 03:10:36 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:LUVINHOME,LLCFACILITY NUMBER:
486803906
ADMINISTRATOR:CAMERINO, ANNY K.FACILITY TYPE:
740
ADDRESS:974 SUFFOLK WAYTELEPHONE:
(707) 999-8276
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 0DATE:
11/16/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anny Camerino, Applicant TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) K. Canela conducted a subsequent pre-licensing inspection, on 11/16/2019 at approximately 10:00 AM, and met with with applicants Anny and Ceazar Camerino by virtual calling. Due to COVID – 19 precautions, a facility visit was not able to be conducted at this time.

The purpose of the subsequent virtual visit was to LPA verify the following corrections:
· proof of Resident rooms are furnished per regulation
· proof of lockable cabinet for toxins (disinfectants and cleaners).
· proof of required postings (LTCO, emergency plan/numbers, CCL complaint poster, Client personal rights to Resident Councils, facility's theft and investigative procedures, and visitor policy)
· construction of concrete patio and ADA ramps in both front and backyard are completed to ensure safety of future residents in care.
  • proof of Night lights in hallway and passages to non-private bathrooms.

During inspection, LPA observed concrete patio/step with metal bolts sticking out of the end. The patio/step is directly outside of the backyard of the home and applicant stated the concrete patio is approximately "6 ft wide" and the step is "about a foot and a half" tall (photos taken). Applicant stated the backyard patio/step was" ADA approved by the city inspector". LPA stated the patio/step with metal bolts sticking out is a potential fall risk and safety hazard to future residents. Applicants will need to add a fence or railing and cover metal bolts to ensure the health and safety of future residents in care in order to proceed with the process for licensure. The applicants shall ensure all facility construction is completed and the facility is ready for move in prior to residents moving in.
Applicants to submit photos as proof of sturdy fence or railing and unexposed metal bolts to LPA to proceed with the licensure process. Applicants to purchase Complaint poster (PUB 475) which shall be 20” x 26” per regulation.

Once LPA obtains pictures, LPA will then notify CAB analyst and submit both pre-licensing application reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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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