486803906-4-25-2024-21-AS-KMOA-D4WSXA-20240503141538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803906
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:58:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240118161109

FACILITY NAME:	LUVINHOME,LLC		FACILITY NUMBER:	486803906
ADMINISTRATOR:	CAMERINO, ANNY K.		FACILITY TYPE:	740
ADDRESS:	974 SUFFOLK WAY		TELEPHONE:	(707) 999-8276
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 2	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	04:21 PM
MET WITH:	Anny Camerino, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility not adhering to program plan and/or admissions agreement
Facility not following general food service requirements
Facility is not safe and in good repair
Staff did not meet residents’ needs

INVESTIGATION FINDINGS:

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On 4/25/2024, Licensing Program Analysts (LPAs) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Anny Camerino. LPA toured the facility, reviewed resident records, made observations, interviewed staff and outside parties during the course of the investigation.

Complaint alleges facility not adhering to program plan and/or admissions agreement. Based on a review of resident (R1) admissions agreement, it was indicated that R1's responsible party, with signatures on file, agreed to pay additional services for R1's meals. The facility provides an adequate amount of meals per day meeting admissions agreement care requirements. Due to contradicting information gathered and R1's Admissions Agreement approving the additional charges, the allegation is found to be unsubstantiated.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240118161109

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUVINHOME,LLC	FACILITY NUMBER: 486803906
	VISIT DATE: 04/25/2024

NARRATIVE

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Complaint alleges, facility not following general food service requirements. Based upon facility tour and observations, LPA found a sufficient and healthy supply of food items for residents in care. In addition, LPA was informed by Administrator that resident (R1) had a vegetarian diet. LPA confirmed that the items located in R1's labeled food containers were specifically for a vegetarian diet. The facility had utilized Meals on Wheels food services for additional food supply, however, facility appears to have sufficient food for resident needs, providing 3 meals and additional snacks per day. Due to contradicting information gathered, the allegation is found to be unsubstantiated.

Complaint alleges, facility is not safe and in good repair regarding grab bars located in resident restrooms to be in disrepair. Upon LPA tour and observations, there are two restrooms available for resident use. LPA found that 1 out of 2 restrooms are in need of a grab bar. Upon interview with Administrator, grab bar replacement orders had been scheduled. In addition, there is still 1 out of 2 restrooms available for resident use with appropriate grab bars installed. Due to conflicting observations the allegation is found to be unsubstantiated.

Complaint alleges, staff did not meet residents’ needs regarding resident (R1) reported to have a sudden change of health condition and reported to be less coherent. Upon LPA's multiple visits, resident (R1) was found to no longer be admitted to the facility for LPA to interview or observe. Due to unavailability of R1 and a lack of corroborating evidence the allegation is found to be unsubstantiated.

A finding that the complaint allegations, facility not adhering to program plan and/or admissions agreement, facility not following general food service requirements, facility is not safe and in good repair and staff did not meet residents’ needs are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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