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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 09/18/2025
Date Signed: 09/18/2025 02:14:31 PM

Document Has Been Signed on 09/18/2025 02:14 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: 4DATE:
09/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Anny Camerino - Licensee/AdminstratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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At approximately 09:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by caregiver Mark Kho who has Designation of Facility Responsibility (RP) who called licensee/administrator Anny Camerino, who arrived at 10:10 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care, three (3) of which are present and one (1) away at day program. Facility is vendorized with the North Bay Regional Center (NBRC).
At approximately 10:20 AM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, without odors 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 be clean, 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 one (1) instance of expired canned food and a technical violation was issued. LPA observed an emergency water supply, as well as, a 124 serving of emergency dry food. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPA observed the locked contents of sheds on either side of the house to be full of additional care supplies and tools. 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 08/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent drill conducted 09/2025.
Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/18/2025
NARRATIVE
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Continued from LIC809...
LPA observed facility's infection control plan and emergency disaster plan which was last updated 09/17/2025. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness.

At approximately 12:45 PM, LPA reviewed four (4) staff files and four (4) resident files. Two (2) of four (4) staff files reviewed were missing required documentation; Staff 1 (S1) was missing proof of health screening by an MD; Staff 2 (S2) did not have a health screening on site for LPA review and licensee was reminded of the requirement to have all resident and staff records on site for review (See LIC809D and repeat penalty). All staff have proof of current First Aid and CPR training. Licensee did provide evidence of initial 40 hours/20 hours annual training.

One (1) of four (4) resident files reviewed were missing required TB screening (see LIC809D) Licensee/Administrator coordinates medical and dental visits for the residents and takes them to their appointments.

Facility does not manage P&I monies.

Updated copies of the following documents are to be submitted to CCL by 10/17/2025
  • LIC500 - Personnel Report (updated)
  • LIC9020 Registration of Facility residents.
  • LIC610E - Emergency and Disaster Plan (updated)
  • Proof of liability insurance**


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 and discussion of two (2) type B violations, one (1) repeat violation and two (2) Technical Violations was conducted with Licensee who voiced understanding and understanding of Plans of Corrections (POCs). Licensee needed to leave before final report could be reviewed and asked that RP sign final reports. Signature on form by RP confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 02:14 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/18/2025 at 01:07 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: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 interview and record review, the licensee did not comply with the section cited above in two (2) out of three (3) persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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Licensee to provide written copy of most recent "good health" report for S2 as well as, provide copy of completed health physical LIC503 for S1. In addition, licensee to submit letter to Community Care Licensing that the licensee and staff have read CCR 87411(f) and understand the requirement to keep a record of staff health screening on site at all times.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 02:14 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/18/2025 at 01:07 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: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in one (1) out of four (4) persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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Licensee submit to letter to Community Care Licensing (CCL) by 10/02/2025 that they have read CCR regulation 87458(c)(1)(A) and provide proof to CCL of evidence of TB testing and negative TB test for R1 by 10/02/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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