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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200818
Report Date: 08/08/2025
Date Signed: 08/08/2025 11:12:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250806163803
FACILITY NAME:RN LOVING CARE HOME IFACILITY NUMBER:
079200818
ADMINISTRATOR:MOU, YUE HUIFACILITY TYPE:
740
ADDRESS:917 ELM STTELEPHONE:
(510) 685-7225
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 6DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yue Hui Mou, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not ensure the facility’s telephone was not in disrepair
INVESTIGATION FINDINGS:
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On 08/08/25 at 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day complaint visit and deliver the findings. LPA was greeted by S3, explained the purpose of the visit, and Yue Hui Mou, Administrator arrived about 15 minutes later.

Allegation: SUBSTANTIATED
Staff did not ensure the facility’s telephone was not in disrepair

Upon receipt of the complaint on 08/06/25, LPA reviewed CCLD’s FAS system and dialed the facility’s telephone number on record and the facility’s mobile number on record. S1 answered the call and confirmed that the telephone number was in fact S1’s mobile number. LPA dialed the facility’s landline twice; at first it rang several times, no messaging service was available, and the call disconnected. LPA immediately called back, and the call was answered by S2 who confirmed that he/she was present at the facility. Continued on LIC9099C...


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250806163803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/08/2025
NARRATIVE
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...continued from LIC9099.

On 08/08/25, LPA tested the landline with S3 while on site at the facility and confirmed the service is working; however, the phone did not ring, S3 was not able to hear the telephone ring in order to answer it. LPA advised S1 to review the following Title 22 regulations: 87468.1 - Personal Rights of Residents in All Facilities and 87311 - Telephones.



Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and a copy of this report provided

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250806163803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
HSC
87468.1(a)(14)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls...-This requirement is not met as evidenced by:
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Licensee/ED to review regulations, provide in-service training for all staff along with signatures, and LPA confirmed phone rang as proof to CCLD by POC date.
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Licensee/ED did not ensure that the facility’s telephone was working properly so that residents could receive incoming calls.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3