486804005-11-7-2023-21-AS-DTOA-CXCVMB-20231107153317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804005
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:33:28 PM

Document Has Been Signed on 11/07/2023 03:33 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:	LOVING HEARTS CARE HOME II		FACILITY NUMBER:	486804005
ADMINISTRATOR:	DATUIN, LUISA		FACILITY TYPE:	740
ADDRESS:	201 GREENMONT DR		TELEPHONE:	(707) 864-6683
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Rose Devera, Administrator		TIME COMPLETED:	03:45 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	On 11/7/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, Rose Devera. The facility is licensed for six non-ambulatory residents and a hospice waiver for three. The facility currently provides care for five residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia tested and found to be in working order. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/12/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Water at faucets accessible to residents was measured between 109.9 and 110.3 degrees which is within regulation. Toxins, sharps and other items that could pose threat if readily available to residents were kept locked under the kitchen and bathroom sinks and within cabinets in the laundry room all of which were found to be secured. During inspection, LPA observed three storage sheds located in the side yard to also be locked and secured. Residents were observed engaging in discussion with staff, watching television shows or resting in their bedrooms. Residents appear to have a positive relationship with staff based on LPA observations. LPA found that the facility is utilizing pest traps in the garage. LPA confirmed with the Administrator and Pest Control company that the services are currently being implemented. Administrator contacted the Pest Control company confirming the services for precautionary measures. The facility conducts emergency disaster drills quarterly with updated logs on record and has a current emergency disaster plan. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 3

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: LOVING HEARTS CARE HOME II	FACILITY NUMBER: 486804005
	VISIT DATE: 11/07/2023

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
26
27
28
29
30
31
32

There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cabinet located in the dinning area were found to be secured. LPA conducted spot medication count and although LPA found Medication Administration Records in order, it was also found that three prescription medications were not properly recorded on the Centrally Stored Medication Record. Administrator will be conducting medication review to properly reconcile prescription information.

LPA also conducted a file review for all residents and found residents to have updated Physician's Reports and Needs & Service Plans. Individual Program Plans for residents under North Bay Regional Center were also found to be current. During a review of staff files, LPA found all staff to have current 1st aid & CPR certification along with adequate annual training on file. Upon review of staff association on Caregiver Background Check roster LPA found that staff S1 was not properly associated to Loving Hearts Care Home II. LPA confirmed with the Regional Office and Guardian search that S1 is currently associated and cleared for two other residential care facilities. Administrator has previously submitted a transfer request for S1 but was not completed. Administrator re-submitted S1's transfer request to the Regional Office during the visit. LPA will follow through confirming the proper association. Technical Violation issued.

Administrator, Rose Devera's Administrator Certificate 6008400740 is currently active through of 11/1/2024.

LPA requested the following documents be sent to CCL by COB 12/7/2023:

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

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/07/2023 03:33 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: LOVING HEARTS CARE HOME II	FACILITY NUMBER: 486804005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on spot medication count, the licensee did not comply with the section cited above in 3 prescription medicaitons not properly recorded on the Centrally Store Medicaiton Records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Administrator agrees to conduct full review/audit of resident medications and properly reconcile prescription information onto the Centrally Stored Medication Records. To submit a LIC9098 Proof of Corrections form confirming compliance by POC date 11/17/2023.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3