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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 06/30/2022
Date Signed: 06/30/2022 10:20:22 AM


Document Has Been Signed on 06/30/2022 10:20 AM - 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: 5DATE:
06/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Staff Member #1, Terecita AbayaTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at A loving Living Home Care for the purpose of conducting a Case Management-Deficiencies inspection. LPA was met at the door by Staff Member #1, Terecita Abaya and was granted access into the facility.

During the tour of the facility at 08:01 AM, LPA observed the auditory device by the rear sliding door leading out to the backyard not operational at the time of the inspection.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 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 a copy of this report along with appeal rights were emailed to the Administrator due to printer issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/30/2022 10:20 AM - 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
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: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2022
Section Cited

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87705(j) Care of Persons with Dementia .The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement was not met as evidenced
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During todays opening of the complaint and facility tour, the sliding door alarm leading out to the backyard not operational. This is a potential risk to residents in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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