486803906-7-2-2026-21-AS-SSTN-DVJR63-20260630124403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 06/30/2026
Date Signed: 07/02/2026 01:58:14 PM

Document Has Been Signed on 07/02/2026 01:58 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,LLC		FACILITY NUMBER:	486803906
ADMINISTRATOR/ DIRECTOR:	CAMERINO, ANNY K.		FACILITY TYPE:	740
ADDRESS:	974 SUFFOLK WAY		TELEPHONE:	(707) 999-8276
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 4	DATE:	06/30/2026
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Anny Camerino - Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

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***Amended Report by Star Stevenson***

At approximately 9:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a Non-Compliance Conference (NCC) inspection and was greeted by caregiver Keyshawn Melton who called Licensee Anny Camerino to advise of today's inspection. Licensee arrived at approximately 10:30 AM to further assist with todays NCC inspection.

The facility was put on an NCC plan for 2 years ending 11/05/27 to bring the facility into compliance.

The purpose of today's inspection was to follow up on areas of prior concern in the operation of the facility operation identified by the department including, but not limited to:

Seeking Timely Medical Care
Prohibited Conditions
Personnel Records
Resident Records
Staff Training Requirements

At approximately 10:00 AM LPA conducted a facility inspection with caregiver Keyshawn Melton and noted the following:
Facility was a comfortable temperature, well lit, and without odors.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

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: 06/30/2026

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*amended report*
continued for LIC809

Refrigerators were noted to be well stocked with a variety of healthy food, but a number of meats were noted to be stored in un-zipped zip lock bags and without the date they were removed from their commercial packaging and a Technical Violation of CCR 87555(b)(9) Food Service requirements was issued (See LIC9102 page)

Water temperatures in sinks available to residents in care were between 105F and 120F as required by title 22 regulations.

Upon entering the room of resident R1, a sheathed approximately 6" sharp knife was noted at bedside. Because of the diagnoses and mobility of other residents in care, licensee was asked to immediately secure R1's knive(s) and to keep them locked. R1 agreed to allow the licensee to remove the knife and secure while this LPA was in the home. Licensee is asked to develop a plan to allow R1 to maintain their knive(s) while keeping other residents safe and submit to LPA the plan by 07/29/2026.

At approximately 10:30 AM, a walk though of backyard and side yard with licensee reveals high brush and grasses have been cut and vegetation over-hanging a storage shed has been cleared back and sharp or tripping hazards that could pose a risk to residents in care have all been removed.

At approximately 11:00 AM LPA reviewed four (4) of 4 resident records and found all 4 had required files.

At approximately 11:30 AM four (4) or four (4) staff files had required documentation as required by Title 22 regulations. All staff present were noted to have background clearance and evidence of required RCFE training hours

Technical Violation is cited from the California Code of Regulations (CCRs), Failure to correct the cited Technical Violation could result in a future civil penalty assessment.

This report was reviewed with Licensee Anny Camerino and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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