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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803906
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:44:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220815131434
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Iris Lopez Santos, Caregiver TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff not meeting resident’s hygiene needs

Facility is unclean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to Luvinhome, LLC for the purpose of delivering findings on complaint # 21-AS-20220815131434. LPA met with Iris Lopez Santos, Caregiver

LPA investigated the above allegations. During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20220815131434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906
VISIT DATE: 09/12/2022
NARRATIVE
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Allegation: Facility staff not meeting resident’s hygiene needs
It was reported to Community Care Licensing (CCL) the Administrator refused to provide direct care (showers or bed-bath) to Resident (R1) who was positive for COVID-19 at the time. Interviews revealed staff did not shower or provide a bed bath to R1 for 1 week due to it being the facility's "policy" to minimize exposure.

Allegation: Facility is unclean
It was reported to CCL the facility was unclean due to the facility bathroom toilet seat was left unclean after resident use. Interviews revealed corroborating statements of observing the toilet seat with dried feces.


Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6), are being cited on the attached LIC 9099-D pages.

Appeal Rights Provided.


Deficiencies cited from the California Code of Regulations, (Title 22, Division 6) on the attached LIC9099-D pages. Failure to correct the deficiencies and/or repeat deficiencies within a 12- month period may result in civil penalties. Exit interview conducted with Caregiver whose signature below confirms receipt of report.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220815131434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited
CCR
87464(f)(4)
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87464 Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...such as...bathing...This requirement was not met as evidenced by:
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Administrator to submit their plan in writing of how they will ensure residents receive personal assitance and care as needed at all times. Written plan to be submitted to Community Care Licensing by 09/19/2022
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Based on interviews conducted, Administrator did not ensure the regulation above due to disclosing they were holding off on showers for resident during isolation. This is a potential health, safety and personal rights risk to residents in care.
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Type B
09/19/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by:
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Administrator to submit their plan of ensuring the regulation 87303(a). Facility to submit a cleaning log for the facility, including the bathroom for 1 week to Community Care Licensing by POC due date 09/19/2022
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Based on interviews conducted, Administrator did not ensure the regulation above due to corroborating statements and witnesses of bathroom observed with dired feces on the toilet seat. This is a potential health, safety and personal rights risk to residents 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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220815131434

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Iris Lopez Santos, Caregiver TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Facility is not providing adequate meals

Facility did not provide assistance with medication

Facility staff threatened resident with eviction

Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to Luvinhome, LLC for the purpose of delivering findings on complaint # 21-AS-20220815131434. LPA met with caregiver Iris Lopez Santos.
LPA investigated the above allegations. During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records. It was reported the facility did not provide adequate meals, assitance with medication, threatened resident with eviction and provided an unlawful eviction to resident. Due to a lack of witnesses and corroborating statements, LPA was unable to prove or disprove the allegation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Caregiver whose signature on this form confirms receipt of these documents.
No deficiencies cited regarding the above allegations during this meeting
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 4