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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 10/17/2024
Date Signed: 10/17/2024 08:17:09 PM

Document Has Been Signed on 10/17/2024 08:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LUVINHOME,LLCFACILITY NUMBER:
486803906
ADMINISTRATOR/
DIRECTOR:		CAMERINO, ANNY K.FACILITY TYPE:
740
ADDRESS:974 SUFFOLK WAYTELEPHONE:
(707) 999-8276
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Anny Camerino, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
08:25 PM
NARRATIVE
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At approximately 12:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Anny Camerino, Licensee/Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. All residents were present during today's inspection. Facility is vendorized with the North Bay Regional Center (NBRC).

At approximately 12:20 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods. LPA observed 5 instances of expired food (See LIC809D). LPA advised Licensee to maintain an emergency water supply as well. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. Licensee states that each resident has their own internet access device. Facility has internet available to residents in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced 08/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent drill was conducted 09/2024.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906
VISIT DATE: 10/17/2024
NARRATIVE
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Continued from LIC809...

LPA observed facility's infection control plan and emergency disaster plan which was last updated 12/2022. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. Licensee provided LPA with a copy of the facility's current liability insurance.

At approximately 1:20 PM, LPA reviewed three (3) staff files and three (3) resident files. Three (3) of three (3) staff files reviewed were missing required documentation; Staff 1 (S1) was missing proof of negative TB results; Staff 2 (S2) was missing proof of a health screening and negative TB results; and Staff 3 (S3) was missing a personnel application and proof of a health screening and negative TB results (See LIC809D). All staff have proof of current First Aid and CPR training. Licensee was unable to provide proof of the required initial 40 hours of staff training for all staff as well as completion of the required initial medication training for all staff (See LIC809D). LPA advised Licensee to ensure compliance with and proof of all staff initial, annual, and medication training and that all are available for review by Licensing upon request. LPA provided Licensee Health and Safety Code (HSC) regulations 1569.625 and 1569.69 for reference. Three (3) of three (3) resident files reviewed were missing the required LIC625 Appraisal and Needs Service Plan (See LIC809D). Licensee/Administrator coordinates medical and dental visits for the residents and takes them to their appointments.

At approximately 5:30 PM, LPA reviewed medications and medication records which are stored in compliance with regulation, However, LPA observed that the centrally stored and destruction medication logs for R1, R2, and R3 were not maintained in compliance with regulation (See LIC809D). Facility does not manage P&I monies.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • LIC610E - Emergency and Disaster Plan (updated)
  • LIC9020 - Resident Roster


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 10/17/2024 08:17 PM - It Cannot Be Edited


Created By: Julie Florio On 10/17/2024 at 06:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 3 staff files reviewed and found missing proof of negative TB results which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee shall submit proof of negative TB results or proof that an appointment for TB testing has been scheduled for all three staff members (including Licensee) to CCL by POC due date 10/18/2024.

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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 10/17/2024 08:17 PM - It Cannot Be Edited


Created By: Julie Florio On 10/17/2024 at 06:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 resident files found missing a care plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee shall complete appraisal and needs services plans for R1, R2, and R3, have them signed by each resident or their responsible party and submit them to CCL by POC due date 11/22/2024.
Type B
Section Cited
CCR
87616(b)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 residents observed to have a peg tube feeding without Licensee having applied for an exception fro CCL, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee shall submit a written request along with the supporting documentation (physician's report, appraisal and needs service plan, statement of how facility will meet the resident's needs and the medical professional who will be caring for the peg tube, as well as statement that staff have been trained for emergency situations, and resident agreement) for an exception regarding R1's peg-tube to CCL by POC due date 10/25/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 10/17/2024 08:17 PM - It Cannot Be Edited


Created By: Julie Florio On 10/17/2024 at 06:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(a)
87465(h)(a) Incidental Medical and Dental Care:
(h)[….] (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident […] includes: (A)The name of the resident for whom prescribed.(B)The name of the prescribing physician.(C)The drug name, strength and quantity.(D)The date filled.(E)The prescription number and the name of the issuing pharmacy.[….]

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 resident medication records inspected which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee shall submit new centrally stored and destruction logs for all three residents in care to CCL by POC due date 11/15/2024.
Type B
Section Cited
HSC
1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on(observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff training records reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee shall submit proof of completion of all required initial training hours for both staff S1 and S2 to CCL by POC due date 11/22/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 10/17/2024 08:17 PM - It Cannot Be Edited


Created By: Julie Florio On 10/17/2024 at 07:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(a)
Employees assisting residents with self-administration of medication; training requirements: Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff medication training records reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee shall submit proof of completion of all required initial staff medication administration training hours to CCL by POC due date 11/22/2024.

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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 10/17/2024 08:17 PM - It Cannot Be Edited


Created By: Julie Florio On 10/17/2024 at 07:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)
The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation the licensee did not comply with the section cited above in 5 instances of expired food found which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee shall submit a self certification that all food in the facility has been inspected and will ensure that no expired food will be in the facility moving forward to CCL by POC due date 11/01/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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