486803906-10-10-2023-21-AS-CFOR-CWGU5V-20231010151723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:17:34 PM

Document Has Been Signed on 10/10/2023 03:17 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:	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:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Macristina Calata, Caregiver		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 10/10/2023 at approximately 9:00am, and met with Macristina Calata, Caregiver. Administrator arrived at approximately 10:19am Administrator Certificate, #6052482740, has expired 06/09/2023 Administrator has applied for renewal. . LPA observed one caregiver working at the time of arrival. There are currently four (4) residents in care.

There is an approved hospice waiver for three (3) residents. Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility last conducted a fire and earthquake emergency drill on 11/02/2022. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval. All exits were free and clear of obstruction. Fire extinguisher, was serviced and tagged as required, expires 07/17/2023. LPA observed seven (7) smoke alarms, including 1 carbon monoxide detector, all working properly during the inspection.

Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 109.4 F, which is within regulation. Medications were stored and locked making them inaccessible to residents in care.

Continue on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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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Document Has Been Signed on 10/10/2023 03:17 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a lose chain on the cabinet door making chemicals accessible, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator tightened chain which made disinfectants, chemicals, cleaning solutions in-accable to residents in care. Deficiency cleared during visit.

Type A

Section Cited

CCR

87465(h)(5)

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Medications shall not be set-up more than 24 hours in advance (one-day only). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by setting medications up for more than 24 hours for 4 of 4 residents which poses an immediate health & safety risk to residents in care. LPA observed containers for 4 residents in a container in the kitchen in a cubby of the cabinet. 7 days of medication is pre-poured at a time, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that medication will not be set-up more than 24 hours in advance. Licensee will submit a written verification that staff and licensee understand medication can never be pre-poured under any circumstance for more than 24 hours in advance signed by all staff. In addition, Licensee to conduct in-service training for all staff and to submit a sign in sheet of attendee's to be submitted to CCL no later then 10/16/2023.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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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: 10/10/2023

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Continue from LIC09

Deficiencies observed during tour:

There are currently four (4) residents in care. LPA reviewed three (3) of four (4) resident files; All resident files were found to be incomplete and missing from the facility.
LPA could not reviewed staff files because they were not located at the facility.
Facility last fire drill was conducted on 11/02/2022.
Chemicals under kitchen sink were accessible to residents in care.
Pre-poured medications 7days +.

LPA is requesting the following documents be updated and submitted by 10/18/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan
Control of property
Copy of Current Liability Insurance
Copy of current Administrator Certificate

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator. Appeal rights were provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 03:17 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(f)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above by not having staff and a resident file not located at the facility and not available to the LPA during normal business hours, which posed a potential health and safety risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Administrator will read and understand regulation and submit self certification to CCL no later then POC date.

Type B

Section Cited

CCR

87705(k)(3)

87705(k)(3) Care of Persons with Dementia-Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview of licensee the facility failed to conduct fire and earthquake drills in the facility at least once every three months which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/14/2023
	Plan of Correction
1 2 3 4	Administrator will conduct a fire and earthquake drill no later then the POC date and provide proof to CCL on 10/16/2023

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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