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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:24:06 PM


Document Has Been Signed on 05/02/2024 03:24 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: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: 4DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Suzette Hojilla, House Manager & Lovelyn Hojilla, LicenseeTIME COMPLETED:
03:40 PM
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On 5/2/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by House Manager, Suzette Hojilla. Licensee, Lovelyn Hojilla arrived later in the visit. The facility currently provides care for 4 residents, two of which are receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with House Manager, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found to be last charged on 4/3/2024 at the time of visit. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings. Staff provide residents with meals according to dietary restrictions with an ample amount of fresh and healthy foods observed.

Cleaning supplies and other toxins are safely stored in locked cabinets in the laundry room, garage all and under kitchen sinks, all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents that were awake during the inspection were observed interacting with staff in the common area, in their bedroom watching television or resting. The facility encourages regular family visits and utilizes outdoor areas for resident exercise and mobility. There are two emergency exits located in the backyard which were found to be unobstructed. There is an outdoor patio with shade and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A LOVING LIVING HOME CARE
FACILITY NUMBER: 486803912
VISIT DATE: 05/02/2024
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LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. All required positing and signeage at the front and hallway of the facility were found to be in order with information easily accessible for staff and residents. LPA will conduct medication review and resident records review at a separate visit.

No deficiency cited.

Licensee's Lovelyn Hojilla's Administrator Certification 6055000735 is currently pending for renewal. Licensee provided confirmation from the Department on training, application received and status on pending list.

LPA requested the following documents be sent to CCL by COB 5/16/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property/Rental Agreement
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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