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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601577
Report Date: 10/11/2022
Date Signed: 10/11/2022 01:50:23 PM


Document Has Been Signed on 10/11/2022 01:50 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR:WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Care Staff, Miesha CopperTIME COMPLETED:
02:05 PM
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On 10/11/2022 at 12:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose for the visit. LPA telephoned Administrator Meina Wu, she's not available to be present, and Care Staff Miesha Cooper is available to assist.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster. LPA was screened at the entry with a thermometer and hand sanitizer. Masks, face shields, gowns, gloves, additional sanitizer COVID-19 signage, and a visitor sign-in log is centrally stored inside the facility that is accessible to all care staff. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs are posted throughout. All shared areas to have covered garbage cans and staff to wear mask while in the presence of others. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap. Hot water temperature was measured at 106.3 degree Fahrenheit (F) and the facility's temperature was 71 degree (F). Fire extinguisher was observed full and last inspected on 03/28/2022. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD by 10/25/2022:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)
-Infection Control Plan
Exit interview conducted and a copy of this report provided to Care Staff, Alis Luna.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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