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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201124
Report Date: 04/21/2023
Date Signed: 04/21/2023 04:42:56 PM

Document Has Been Signed on 04/21/2023 04:42 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:
04/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Mynette BoykinTIME COMPLETED:
05:00 PM
NARRATIVE
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On 04/21/2023 at 9:00 AM, Licensing Program Analyst (LPA) J Sampair arrived unannounced for this follow up post-licensing inspection. Upon entry, LPA disclosed the purpose of the visit to Caregiver Hilda Manuel who informed Licensee Mynette Boykin who arrived at 10:15 AM.

Inspection completed.

2 Type B deficiencies cited during inspection (refer to LIC809-D for details).

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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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
Document Has Been Signed on 04/21/2023 04:42 PM - It Cannot Be Edited


Created By: James Sampair On 04/21/2023 at 03:03 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: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA experience and records review, the licensee did not comply with the section cited above because the Administrator is not at facility a minimum of 20 hours per week during regular work hours (8 AM to 5 PM Monday - Friday), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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On or before the due date, Licensee shall inform the LPA of the appointment of an Administrator who will be at the facility a minimum of 20 hours per week during regular work hours (8 AM to 5 PM Monday - Friday).
Type B
Section Cited
CCR
87506(b)(17)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following:

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 4 of the 4 resident records that were missing records required by Title 22 (A) Section 87457, Pre-Admission Appraisal, Functional Capabilities, Mental Condition, Social Factors, and Reappraisals, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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On or before due date, Licensee shall fully complete, file, and print all required documentation for all staff and residents, including signatures and dates. Licensee shall inform LPA when she has completed this requirement.
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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2