486803912-6-5-2023-21-AS-KCAA-CSJ2TL-20230605174053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 06/05/2023
Date Signed: 06/05/2023 05:42:32 PM

Document Has Been Signed on 06/05/2023 05:42 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 CARE		FACILITY NUMBER:	486803912
ADMINISTRATOR:	LOVELYN HOJILLA		FACILITY TYPE:	740
ADDRESS:	224 LOCH LOMOND DRIVE		TELEPHONE:	(707) 469-9029
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 5	DATE:	06/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Lovelyn Hojilla, Administrator		TIME COMPLETED:	05:58 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	Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and was granted access into the facility by Suzette Hojilla, Caregiver. Administrator Lovelyn Hojilla arrived later. LPA toured the facility, all exits were unobstructed. The facility was found to be at a comfortable temperature. LPA observed a supply of linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Resident bedrooms were furnished per regulation. Facility food supply was within regulation and accessible to clients. Medication was centrally stored. Water temperature was tested and observed between 105 to 120 degrees F. Disaster Drills are conducted quarterly as required. Fire extinguisher was charged and serviced 04/07/2023. There are 8 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational. LPA reviewed staff and resident records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. LPA addressed fire clearance and postural supports deficiencies on continued page (LIC809-C). LPA discussed regulations 87465(h)(5), 87463(c), 87463(a); and discussed Health & Safety Code 1569.696(a)(1) & 1569.625(b)(2) LPA requested the following updated forms to be submitted to Community Care Licensing by 07/06/2023: · LIC 308 Designation of Facility Responsibility (1 person per form) · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents) · Copy of Liability Insurance · LIC 9020 Facility Register of Client/Residents · LIC 610E Emergency Disaster Plan · Copy of current Administrator's Certificate Report continued on LIC809-C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

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: 06/05/2023

NARRATIVE

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Deficiencies observed:

Fire Clearance Violation:

During inspection, LPA observed 1 shed in the backyard on the facility property with a bed, television, dresser, air conditioner, food, and personal belongings (photos taken). Staff (S1) stated they live in the shed with their partner non-client adult resident (NCAR). Administrator stated the shed is a relief room for staff staying over night; S1 and NCAR stay in the staff room inside the facility adjacent to the kitchen. LPA discussed with Administrator that the shed is required to be inspected and approved by the Vacaville Fire Department to ensure it is safe for staff to occupy. Administrator understood.

Additionally Administrator disclosed Resident (R1) occupying bedroom #1 is bedridden, as they can't turn in their bed and can't ambulate without the use of a wheelchair. LPA discussed with Administrator that the Vacaville Fire Department approved bedroom #5 for bedridden (per facility sketch received 05/20/2020) and bedroom #1 is approved for only non-ambulatory.

Postural Supports Violation:

During inspection, LPA observed 5 of 5 residents with half-rails (photos taken). LPA discussed with Administrator that half-rails are only allowed if the resident's medical physician provides an order for half-rail to be used for mobility and support per regulation. Administrator stated they understood.

**An immediate civil penalty in the amount of $500 was assessed today for the fire clearance violation.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Provided.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer issues, this report was emailed to Administrator

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2023 05:42 PM - 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: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 shed in the backyard occupied by staff and /or non-client resident and has not been approved by the Fire Department to live-in, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2023
	Plan of Correction
1 2 3 4	Licensee to not allow anyone to live or otherwise occupy the shed, or request an updated fire clearance inspection for the Fire Department to approve the shed for living use. Request for fire clearance to include an updated facility sketch and LIC200 request form. Send request to DSS Community Care Licensing. Administrator submitted POC during inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2023 05:42 PM - 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: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, the licensee did not comply with the section cited above in 5 out of 5 residents observed with half-rails and R1-R5 do not have doctor's orders (for mobility and support) for half rails which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	Licensee to obtain doctor's orders for mobility and support to use half-rails or take off half-rails. Licensee to submit doctor's orders for mobility and support for half-rail use to Communict Care Licensing to clear the POC by POC due date 06/19/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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