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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 05/07/2025
Date Signed: 05/07/2025 01:49:05 PM

Document Has Been Signed on 05/07/2025 01:49 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: DATE:
05/07/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Anny Camerino and Cesar CamerinoTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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At approximately 1:05 PM, an office informal meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager (LPM), Bethany, Licensing Program Analyst (LPA), Julie Florio and Star Stevenson and Administrator Anny Camerino and licensee Cesar Camerino.

The purpose of today's meeting is to deliver findings of a complaint investigation and discuss a self-reported incident report to Community Care Licensing (CCL) on 3/27/2025. The incident report received informed that Resident's (R1) pressure injury was observed to have "gotten worse.” 3/26/2025 R1 was sent out 911 due to on-going pressure injury and additional change of condition. LPAs requested additional documents and upon review it has been determined that the facility retained R1 with a prohibited condition and failed to seek timely medical. On 3/14/2025 R1 was admitted to the LuvinHome facility with, per Skilled Nursing Facility (SNF) discharge documents on 2/11/2025 with a stage 4 pressure injury on sacral region. Medical assessment obtained, dated 1/23/2025 indicates a stage 2 pressure injury in same location. Preplacement assessment dated 3/6/2025 does not document any wound. Upon discharge from SNF, document dated 3/14/2025 was provided to facility indicating stage 4 pressure injury and discharge orders for home health. From admission to Luvinhome on 3/14/2025 to R1 being sent out 911 on 3/26/2025, R1 had no home health or wound care resulting in wound getting worse. R1 was admitted to the hospital on 03/26/2025. Administrator informed that there were attempts to contact physician to implement home health but were unsuccessful.

An immediate $500 civil penalty is being issued today. The administrator and licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

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.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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Document Has Been Signed on 05/07/2025 01:49 PM - It Cannot Be Edited


Created By: Star Stevenson On 05/07/2025 at 08:44 AM
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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2025
Section Cited
CCR
87615(a)(1)

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87615 Prohibited Health Conditions: (a) Persons who require health services for... those specified below... shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on interviews and
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Administrator will submit to Community Care Licensing (CCL) a letter of understanding that they have read and understand Regulations 87615 (Prohibited Health Conditions) and 87616 (Exceptions for Health Conditions) by POC Due Date of 05/08/2025.
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record review, administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/08/2025
Section Cited
CCR87645(a)(2)

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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...(2) The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement is not met as evidence by: Based on interviews and
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Administrator will submit to Community Care Licensing (CCL) a letter of understanding that they have read and understand Regulations 87645 (Incidental Medical and Dental Care) by POC Due Date of 05/08/2025
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record review, administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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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: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
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