<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803912
Report Date: 01/27/2022
Date Signed: 01/27/2022 10:46:24 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211129134113
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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emelda GoodTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death.
Staff did not obtain medical care for resident in a timely manner.
Food service is inadequate.
Resident medication was not locked.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Emelda Good and discussed findings. Complainant alleges that R1's death is questionable due to facility staff's failure to obtain timely medical care; facility's failure to provide sufficient nourishment for R1; and that the refrigerated medications were not kept secure. This Department's investigation has included site visits to facility; review of documents; and statements from staff and witnesses. The following determinations are made: R1 left the facility on 10/20/2021 for emergency care and did not return; R1 died on 11/05/2021 while in skilled nursing; Cause of death was determined to be from an incurable illness from which R1 suffered for many years and Alzheimer's Dementia; Staff report that R1's condition was stable on the days preceding her hospitalization although R1 was sleeping more and eating less but was alert; No refrigerated medications were stored at time of site visits; all staff report the medications were kept secure; Facility notes and records suggest that R1 was monitored by staff and that medical care was obtained when staff noted change in condition of R1. Although the allegations may be true, or valid, based upon observations, statements, and records, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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
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
11/29/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211129134113

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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emelda GoodTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Adult present in the facility not finger print cleared.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Complainant alleges that a male adult, presumed to be P1, is frightening and hides when Complainant enters the facility and may not be cleared to be present. This investigations has included record searches and reviews; interviews with staff and witnesses and the following determinations are made: P1 is a friend of the Administrator and is sometimes present in the facility; This Department has verified that P1 has been criminal record cleared and associate to the facility as of October 27, 2021, which is prior to the receipt of this complaint. Based upon the interviews and records reviews, this complaint is UNFOUNDED, meaning that it is not true and/or, has no reasonable basis. The allegation is DISMISSED.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 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
11/29/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211129134113

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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emelda GoodTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist with administrations of medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
It is alleged that R1 had very low blood sugar when admitted to a medical setting and that unused medications suggested that it had not been administered to R1. This Department has reviewed documents and taken statements while investigating this complaint and now makes the following determinations: The unused medications were not measured of photographed and remain an allegation; R1 may have refused medications during last days at facility but facility does not maintain a Medical Administration Record; R1’s physician ordered that R1’s blood sugar be tested “3 to 4 times per week” in Physician’s Report dated 9/28/2021; Facility blood sugar chart for R1 indicates that R1’s sugar level was tested only twice between 9/28 and 10/10/2021. Based upon the statements taken and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and 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 and report left at facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20211129134113
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: A LOVING LIVING HOME CARE
FACILITY NUMBER: 486803912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2022
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***This requirement has not been met as evidenced by: Based upon statements and records, R1 was not tested
1
2
3
4
5
6
7
Administrator shall secure additional training for all staff that addresses the issue of caring for residents who require blood sugar monitoring and the administration of insulin. The plan will comply with the requirements of 87628 and will be submitted to CCL by POC date and follow -up confirmation of the training in order to clear the deficiency.
8
9
10
11
12
13
14
for blood sugar as frequently as order by R1’s physician. This posed an immediate risk to the health of R1.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4