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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201256
Report Date: 06/13/2025
Date Signed: 06/13/2025 03:54:14 PM

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
06/05/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250605113309
FACILITY NAME:A LOVING HOMEFACILITY NUMBER:
079201256
ADMINISTRATOR:ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:3420 CLAYBURN RD.TELEPHONE:
(951) 522-1228
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 4DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donnie Aloot, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff modified the resident's medical device without authorization
INVESTIGATION FINDINGS:
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On 06/13/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, LPA interviewed residents (R1, R2, R3) & staff (ADM, S1), toured the facility with S1 and obtained the following documents from ADM - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Needs & Services plan and incident reports.

Continued on next page, LIC 9099_C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
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 5
Control Number 15-AS-20250605113309
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: A LOVING HOME
FACILITY NUMBER: 079201256
VISIT DATE: 06/13/2025
NARRATIVE
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Allegation: Staff modified the resident’s medical device without authorization
Investigation Finding: Substantiated
During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1) & R1’s responsible party (POA) and reviewed resident's(R1) documents. ADM confirmed with LPA that R1's medical device was modified without her authorization to enable them to plug her medical device into the existing 2 prong ungrounded bedroom outlet. LPA observed all residents' bedroom outlets(Rms 1, 2, 3) had two prong ungrounded outlets. LPA observed only the kitchen area had grounded three prong electrical outlets. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff modified the resident's medical device without authorization was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099-D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/05/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250605113309

FACILITY NAME:A LOVING HOMEFACILITY NUMBER:
079201256
ADMINISTRATOR:ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:3420 CLAYBURN RD.TELEPHONE:
(951) 522-1228
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 4DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donnie Aloot, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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2
3
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5
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9
Staff do not ensure residents receive bathing services in a timely manner
INVESTIGATION FINDINGS:
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2
3
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5
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10
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On 06/13/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, LPA interviewed residents (R1, R2, R3) & staff (ADM, S1), toured the facility with S1 and obtained the following documents from ADM - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Needs & Services plan and incident reports.

Continued on next page, LIC 9099-C pg 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250605113309
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: A LOVING HOME
FACILITY NUMBER: 079201256
VISIT DATE: 06/13/2025
NARRATIVE
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Allegation: Staff do not ensure residents receive bathing services in a timely manner
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S1) and residents (R1, R2, R3). Residents (R1, R2, R3) confirmed with LPA that staff give them daily bed baths. R1 stated staff gives her a full shower every 7 days aside from getting bed baths. Staff confirmed with LPA that all non-ambulatory residents are given bed baths daily with R1 being given a full shower every Thursday. Staff denied not giving R1 a full bath over 13 days. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not ensure residents receive bathing services in a timely manner is unsubstantiated.

Exit interview conducted and a copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250605113309
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: A LOVING HOME
FACILITY NUMBER: 079201256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2025
Section Cited
CCR
87203
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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
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By POC due date, ADM agreed to replace all ungrounded outlets with three prong grounded outlets and submit photo of receipt for repairs in compliance with Section 87203 regulations.
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This requirement was not met as evidenced by staff modified resident's medical device without authorization which posed a potential health & safety risk to residents in care.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5