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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:06:30 AM

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 CAREFACILITY NUMBER:
486803912
ADMINISTRATOR:LOVELYN HOJILLAFACILITY TYPE:
740
ADDRESS:224 LOCH LOMOND DRIVETELEPHONE:
(707) 469-9029
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lovelyn HojillaTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) K, Walters and J. Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by Licensee. Lovelyn Hojilla (6055000740 exp 1/5/2022). LPAs conducted a Risk Assessment with Administrator. There were 4 staff providing care and supervision for 6 residents. LPAs observed that all staff were wearing face mask and disposable gloves.

LPAs temperatures were checked upon entry and logged into a binder. Hand sanitizer and disposable mask were available. LPAs/Licensee conducted a tour through the facility and observed that the facility was a comfortable temperature of 72 and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available.

Signs were posted throughout the facility to promote hand washing and social distancing. Residents temperatures are being monitored daily and results are documented in residents binders. Facility has a 60 day supply of PPE stored in the garage. Facility has a 30-day supply of medication for residents. Facility has conducted staff training on infection control. Administrator will have all staff fit tested for N95 mask. LPAs provided Administrator with a copy of PIN 21-10. LPAs is requesting that the Administrator make changes to their mitigation plan and send a copy to Community Care Licensing CCL attention LPA Walters by 6/15/2021.

No deficiencies were cited during today's inspection.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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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