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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200595
Report Date: 08/25/2022
Date Signed: 08/25/2022 01:10:59 PM

Document Has Been Signed on 08/25/2022 01:10 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:LOVING HEART CARE HOMEFACILITY NUMBER:
079200595
ADMINISTRATOR:VAHID SANTOS, ELVIRAFACILITY TYPE:
740
ADDRESS:2652 CARSON WAYTELEPHONE:
(925) 948-5221
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 4DATE:
08/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Elvira Vahid Santos, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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On 08/25/22 at 12:34PM, while at the facility for another reason, LPA observed that the one car garage was converted into a one bedroom unit which is a violation of the facility's approved fire clearance dated 10/25/17. LPA discussed the fire clearance violation with administrator.

Immediate civil penalty of $500 assessed on today's date.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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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Document Has Been Signed on 08/25/2022 01:11 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 08/25/2022 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LOVING HEART CARE HOME
FACILITY NUMBER: 079200595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
CCR
87202(a)

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(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.
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Administrator agreed to secure and submit to CCLD a copy of Fire Clearance as soon as possible.

Immediate $500 civil penalty assessed for fire clearance violation.
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This requirement was not met as evidenced by failure of staff to notify the fire department of the one car garage conversion to a bedroom unit which posed an immediate health & safety risk to residents in care.
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Deficiency cleared during visit.
Administrator contacted local Fire Department on 08/25/22 and submitted fire clearance application for renovated one car garage.

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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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