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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:37:15 PM


Document Has Been Signed on 09/12/2022 05:37 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 2DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Iris Lopez Santos, Caregiver TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) K. Canela arrived unannounced for the purpose of delivering findings on complaint investigation # 21-AS-20220815131434. During inspection, LPA observed deficiencies. LPA consulted with staff regarding the following requirements. Facility to correct deficiencies observed to avoid citations in the future.

    1.) LPA observed nonperishable food supply to be low (photos taken). LPA consulted with facility to maintain a minimum of 1 week supply per regulation.
    2.) Surveillance testing requirements
    3.) LPA observed solid waste in bathroom #2 in a trash can without a lid (photos taken). LPA previously discussed with Administrator on 07/01/2022 that trash cans require a tight-fitting lid.
    4.) LPA observed an odor in bathroom #2 from trash can observed with solid waste. LPA brought it to the attention of staff who immediately cleaned and emptied the trash. LPA discussed the facility is to remain free from odors per regulation
    5.) Reporting requirements
    6.) LPA observed a hole in the wall inside bathroom#2 with exposed wires covered by painters tape. Facility to ensure the facility is in good repair at all times per regulation

No citations issued for the above deficiencies observed at this time, the facility received technical violations.

Exit interview conducted with caregiver, whose signature below confirms receipt
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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