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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200818
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:06:36 PM

Document Has Been Signed on 03/14/2025 04:06 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:RN LOVING CARE HOME IFACILITY NUMBER:
079200818
ADMINISTRATOR/
DIRECTOR:		MOU, YUE HUIFACILITY TYPE:
740
ADDRESS:917 ELM STTELEPHONE:
(510) 685-7225
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Yue Hui Mou and Jianyin Lou (Administrators) TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 03/14/25 at 08:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Yue Hui Mou and Jianyin lou Administrator (ADMs) and explained the purpose of the visit.

LPA and ADMs the toured facility including, but not limited to bedrooms, bathrooms, kitchen, dining room, common area, front yard, and backyard. All outdoor and indoor passageways were free of obstruction. There were not any bodies of water observed. A comfortable temperature was maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The hot water temperature in the residents’ shared bathroom was last measured at 115 degrees Fahrenheit. Residents’ bathrooms were equipped with grab bars and non-skid mats. There was a minimum of one week supply of non-perishables and 2 days of perishable foods. Centrally stored medications and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition. Fire extinguisher was observed full. Emergency Disaster Plan was last posted on 04/10/24. First aid kit was observed to be complete. Safety drill was conducted last quarter.

LPA reviewed six (6) residents records; Of four (4) staff records; three (3) staff were complete.

Continued on LIC9099C...
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: RN LOVING CARE HOME I
FACILITY NUMBER: 079200818
VISIT DATE: 03/14/2025
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...continued from LIC9099.

The following forms are to be updated and submitted to CCLD 03/17/25:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Pending)
-Liability Insurance (Reviewed, exp:11/2025)
-Proof of CPR

Exit interview conducted and a copy of this report provided to ADMs.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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