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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200819
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:05:43 PM


Document Has Been Signed on 05/16/2023 03:05 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 IIFACILITY NUMBER:
079200819
ADMINISTRATOR:LOU, JIANYINFACILITY TYPE:
740
ADDRESS:921 ELM STTELEPHONE:
(510) 816-1173
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 6DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Co-Administrator, Yue 'Andy' MouTIME COMPLETED:
02:00 PM
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05/16/23 at 11:05 AM; Licensing Program Analyst (LPA) L. Holmes conducted an unannounced required annual inspection. LPA met with Co-Administrator (ADM) Yue 'Andy' Mou, and explained the purpose of the visit. ADM currently holds a certificate (#6048517740) that expires on 07/25/24. The facility’s fire clearance was approved for six (6) non-ambulatory residents; all six (6) may be non-ambulatory and two (2) may be hospice.

Upon arrival LPA observed two (2) staff attending to residents. LPA and ADM toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and outside yard area. The facility consists of six (6) bedrooms that are individually occupied by the residents. A comfortable temperature was maintained at 76 degrees Fahrenheit (F). LPA observed lighting in all rooms to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents bathrooms measured at 114.3. All bathrooms were safe with hand rails and non-skid surfaces. Signs to promote social distancing, hand washing, and COVID-19 prevention were posted throughout. All areas were sanitary and in operating condition. Linen and hygiene products were available for residents. PPE, sanitizer, and paper goods are sufficient. All outdoor and indoor passageways are free of obstruction. There are not any bodies of water.

...continued on LIC809C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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 2


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 II
FACILITY NUMBER: 079200819
VISIT DATE: 05/16/2023
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...continued from LIC809

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was inspected on 02/22/23 and was full. Emergency Disaster Plan to be updated with shelter information. First aid kit was complete and fire drills are conducted quarterly.

Three (3) of three (3) staff records were reviewed, and all staff have criminal record clearance. Five (5) of six (6) resident records reviewed were current and complete.

The following forms are to be updated and submitted to CCLD 05/30/23:
-Resident roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-Update staff file with first aid/CPR certification
-Update staffs annual training records
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2