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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:13:55 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: 2DATE:
10/29/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ceazar Camerino, LicenseeTIME COMPLETED:
02:23 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Post-Licensing inspection and met with Licensee Ceazar Camerino, and Licensee & Administrator Anny Camerino who arrived later. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA conducted a walk-through of the facility with Licensee and observed a COVID-19 screening station at front entrance of the facility to screen anyone entering (staff, essential and non-essential visitors). Screening station includes hand sanitizer, a thermometer, COVID-19 screening questionnaire, and a sign-in sheet for visitors and staff. LPA observed 1 resident in care. Licensee stated staff clean and disinfect the facility two - three times a day and as needed. A designated visitation area is available and staff provide phone calls for family to stay in contact with residents. There is a supply of PPE including gloves, face shields, N-95 respirators, and surgical masks. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. Licensees wore masks during this visit.
LPA discussed the following with Licensees:
· Documenting vaccination status (and/or negative COVID test taken within 72 hours) for visitors and staff entering the facility.
· Requirements and guidance from Provider Information Notice (PIN) 21-40-ASC.
· Daily temperature checks & documentation for residents and staff.
· N-95 respirator Fit testing (Cal/OSHA requirement) for staff.
· Documenting staff training on infection prevention, symptoms, transmission and PPE use.
· Locked storage requirements for medication, disinfectant and cleaning solutions.
· Fire safety and clearance request of approval from CCL to lock exterior doors or perimeter fence gates.
· Emergency Disaster Drills to be conducted every 3 months.
· Fire extinguisher to be tagged (service date) by the fire department.
· CCL COVID-19 precaution postings (LPA to send copies to licensee).
LPA provided the regulations for the above requirements.
Exit interview conducted with Administrator, whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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