486803912-6-2-2020-21-AS-DTOA-BQ7UX7-20200602155752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 05/29/2020
Date Signed: 06/02/2020 03:58:57 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:	A LOVING LIVING HOME CARE		FACILITY NUMBER:	486803912
ADMINISTRATOR:	SADDI, DONABELL W.		FACILITY TYPE:	740
ADDRESS:	224 LOCH LOMOND DRIVE		TELEPHONE:	7074699029
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 6	DATE:	05/29/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lovelyn Hojilla, Administrator Applicant		TIME COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/29/2020 Licensing Program Analyst (LPA) Dominic Tobola conducted a video tele-visit for the purpose of completing a pre-licensing evaluation. This pre-licensing inspection is being conducted due to a change of ownership. The video tele-visit must be conducted due to COVID-19 restrictions. LPA was greeted by Licensee Donabell Saddi and Administrator Applicant Lovelyn Hojilla and conducted a tour of the facility. The facility is a 6 bedroom 2 bathroom single story house. There are 6 residents in care some of which are diagnosed with Dementia. 2 of 6 resident are on hospice. LPA toured the entire premise which was found to be clean and orderly. Fire extinguisher last inspected 4/10/2020 was mounted and charged. Smoke detectors tested and found to be in working order. Carbon monoxide detector was located in the resident hallway and found to be in working order. Medications, facility files, emergency supplies and sharps are stored in a locked closet in near the kitchen. Toxins and cleaning supplies are secured in a locked laundry room leading to the garage. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 5 clients. There is a closet located in the resident hallway that holds extra linens and towels. Beds were made with appropriate linens. Furniture is appeared safe and adequate. Hot water temperature was measured between 113.5 and 114.1 degrees F and within regulation between 105 degrees F and 120 degrees F. There was an ample supply of dishes and cooking supplies. Required postings such as Complaint poster, Rights to resident councils, client's rights are posted in the facility. Resident and staff records, all contained required documentation and secured in the medication closet. Report continued on LIC809-C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

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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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: A LOVING LIVING HOME CARE	FACILITY NUMBER: 486803912
	VISIT DATE: 05/29/2020

NARRATIVE

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A fire clearance for this facility has been granted for 1 bedridden and 5 non-ambulatory clients. An emergency exit along the side of the facility is unobstructed and equipped with self closing latches.

Component III orientation was conducted with the Licensee and Administrator Applicant.

The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Centralized Application Unit for continued processing.

This report was reviewed with applicant and a copy was provided.

No deficiencies were cited during today's visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

LIC809 (FAS) - (06/04)

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