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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201124
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:56:08 PM

Document Has Been Signed on 04/13/2023 05:56 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 TOUCH CARE HOMESFACILITY NUMBER:
079201124
ADMINISTRATOR:BROOME, MERCEDESFACILITY TYPE:
740
ADDRESS:285 EBANO DRTELEPHONE:
(925) 393-5779
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 4DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Mynette BoykinTIME COMPLETED:
06:00 PM
NARRATIVE
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On 04/12/2023 at 1:00 PM, Licensing Program Analyst (LPA) J Sampair arrived unannounced to complete the Post-Licensing Inspection that began 04/05/2023. LPA explained purpose of the visit to staff member Hilda Manuel who informed Licensee Mynette Boykin by phone. Licensee arrived at facility at 2:15 PM.

3 deficiencies cited during inspection.

Inspection incomplete and will be continued at a future date.

Exit interview conducted with Licensee. Copy of this report provided via email.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 4
Document Has Been Signed on 04/13/2023 05:56 PM - It Cannot Be Edited


Created By: James Sampair On 04/13/2023 at 04:44 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 TOUCH CARE HOMES
FACILITY NUMBER: 079201124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the garage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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Licensee must remove temporary walls and excess items from the garage, and subsequently maintain the garage in a neat and orderly fashion with minimal combustible storage in it on or before the due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/13/2023 05:56 PM - It Cannot Be Edited


Created By: James Sampair On 04/13/2023 at 05:06 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 TOUCH CARE HOMES
FACILITY NUMBER: 079201124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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3
4
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of the 2 employee files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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Licensee shall update the Plan of Operation to include a process for propey completion of forms to ensure that they are complete with signatures, dates, and completion by a licensed physuician for all personnel and that all will fulfills the Title 22 regulations. Additionally, the licensee shall complete all required documentation for all employees by the due date or have appointment scheduled.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/13/2023 05:56 PM - It Cannot Be Edited


Created By: James Sampair On 04/13/2023 at 05:06 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 TOUCH CARE HOMES
FACILITY NUMBER: 079201124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 4 of 4 employees, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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Licensee shall update the Plan of Operation that includes training and documentation of having completed that training for staff that fulfills the Title 22 regulations. Additionally, the licensee shall obtain an outside training company for medication administration and any other training that the facility is unable to provide for all staff.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4