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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 11/29/2021
Date Signed: 11/29/2021 01:16:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LUVINHOME,LLCFACILITY NUMBER:
486803906
ADMINISTRATOR:CAMERINO, ANNY K.FACILITY TYPE:
740
ADDRESS:974 SUFFOLK WAYTELEPHONE:
(707) 999-8276
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 1DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Anny Camerino. Licensee/AdministratorTIME COMPLETED:
01:27 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required 1 - Year inspection and met with Licensee & Administrator Anny Camerino and Licensee Ceazar Camerino, who was also present. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA reminded Administrator to keep her face mask on at all times when in the facility. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility to screen anyone entering the facility (staff, essential and non-essential visitors). Screening station includes hand sanitizer, a thermometer, COVID-19 screening questionnaire, and a sign-in sheet for visitors and staff. LPA observed 1 resident in care. Administrator took LPA's temperature and screened LPA for COVID-19 symptoms.
Administrator stated client's temperatures are taken once a day and LPA observed documentation. .
A designated visitation area is available and staff provide phone calls for family to stay in contact with residents. There is a supply of PPE including gloves, face shields, N-95 respirators, disposable gowns, and surgical masks.
The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to be reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed N-95 respirator Fit testing (Cal/OSHA requirement).

LPA discussed requirement of staff needing to be fully vaccinated OR have an exemption in file (religious or medical) and they must test weekly per PIN 21-44-ASC: Adult and Senior Care Facility Worker Coronavirus disease 2019 (COVID-19) Vaccination Requirement.

Report Continued on LIC809-C....
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906
VISIT DATE: 11/29/2021
NARRATIVE
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During inspection the following was observed:
2 of 2 fence gates were observed locked with a dead-bolt lock (one in back yard & one in front side yard fence gate) preventing the gates from opening; pictures taken and in file. The facility does not have clearance from the Fairfield Fire Department or Community Care Licensing (CCL) for a locked perimeter. LPA asked licensee to remove the dead-bolt locks, Anny removed the locks during inspection. Licensee Ceazar stated he, Anny, and the resident's family feel safer with the gate locked, "even though its a safe neighborhood, you never know". Licensee/Administrator stated they lock the fence gate because they have smelled marijuana outside before and they feel safer with the gate locked. Anny stated the facility does not lock the resident in since they need assistance walking and would not go out the back yard to exit because staff are always present.
During the facility's post-licensing visit on 10/29/2021, LPA explained the regulation requirements and warned licensees they could not lock the fence gates without an approved waiver from the CCL and fire clearance from the fire department. LPA provided the regulations to assist with the waiver request during post-licensing inspection. LPA observed the 2 perimeter fence gates were locked and asked Ceazar to remove the 2 dead-bolt locks during the post-licensing inspection. Ceasar and Anny stated they would request a waiver approval from CCL to lock the fence gates since they did not know at the time that they could not lock the perimeter gates and felt safer with a locked fence.
As on 11/29/2021, CCL and LPA have not received a waiver request regarding locking the perimeter fence gates.

Additionally, Licensees stated a new resident will be admitted to the facility the first week of December 2021. The resident is on hospice. LPA discussed with Licensees that they can not admit a hospice resident to LuvinHome, LLC until they have requested a hospice waiver or exception and it is approved by CCL.

LPA provided the regulation 87405(d)(1)(2) Administrator - Qualifications and Duties to Licensee/Administrator Anny Camerino

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Immediate Civil Penalty assessed in the amount of $500 during today's inspection.
Appeal rights given. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2021
Section Cited

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on LPA's observation and interviews, Licensees did not ensure the regulation above by locking the 2 of 2 perimeter gates with dead-bolt locks. This is an immediate health, safety and personal rights risk to residents in care.
**Immediate Civil Penalty assessed in the amount of $500.
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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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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