197610274-7-8-2025-31-AS-ERIS-DJDUKG-20250708153908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610274
Report Date: 07/08/2025
Date Signed: 07/08/2025 03:39:19 PM

Document Has Been Signed on 07/08/2025 03:39 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOREVER LOVE HOME CARE INC.		FACILITY NUMBER:	197610274
ADMINISTRATOR/ DIRECTOR:	BELMONTE, MARK		FACILITY TYPE:	740
ADDRESS:	44920 LOTUS LN.		TELEPHONE:	(661) 206-7518
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	07/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:50 AM
MET WITH:	Mark Belmonte -		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Annual Required visit for this facility. LPA met with the administrator, Mark Belmonte and explained the reason for the visit. The facility is licensed for a total capacity of six (06) with fire clearance for five (05) non-ambulatory residents, and one (01) bedridden. At approximately 12:00 p.m., LPA and administrator toured the physical plant of the facility inside and out and the following was observed: At entry LPA observed a sign in log for visitors and a digital thermometer affixed to the wall. LPA observed appropriate postings. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility, properly stored. Knives and sharps were stored in a locked kitchen drawer. LPA observed cleaning supplies locked under the kitchen sink cabinet. Centrally stored medication was observed locked in a kitchen cabinet. One (01) fire extinguisher in the kitchen was observed fully charged with service date 07/12/2024. Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards and fenced in. No bodies of water observed. There are dual carbon monoxide and smoke detectors that are hard wired and interconnected though out the facility. Administrator tested detectors at 12:25 p.m., and LPA observed detectors functioning properly. Fire door closed when test was conducted. (Continue to LIC809)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOREVER LOVE HOME CARE INC.	FACILITY NUMBER: 197610274
	VISIT DATE: 07/08/2025

NARRATIVE

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(Continued from LIC809) Bedrooms: Five (5) bedrooms are designated for resident use one (1) of which may be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient storage and lighting. One (1) hallway cabinet was observed to have first aid kit and first aid kit supplies. Another closet stored extra linens and towels.

Bathrooms: There are three (3) bathrooms available for residents' use. Bathrooms were supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured from two (02) bathrooms at 12:30 p.m., and read 111 degrees Fahrenheit, within regulation.

Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches and arm chairs where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. During visit LPA observed residents sitting in the living room with family visitors. LPA observed two (2) portable telephones accessible to residents.

Laundry and Garage: The laundry room is located in the hallway by the residents' rooms and leads to the attached garage. Laundry room was observed locked. Detergents and cleaning supplies were observed locked in the laundry room. LPA observed a freezer and a refrigerator in the garage with extra food.

Resident, Staff, and Facility Files: At 12:57 p.m., LPA conducted a file review of five (5) out of five (5) resident records to ensure compliance of licensing forms. LPA also conducted a file review of two (2) staff records to ensure forms and training are up to date and in compliance with licensing forms. LPA reviewed facility's liability insurance and emergency disaster plan (LIC610E.) Facility had not documented an emergency disaster drill for their last quarter.

Medications: At 2:27 p.m., LPA reviewed Medication and Medication Records. Medications were reviewed for proper storage and documentation. Facility also maintains a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC809 (FAS) - (06/04)

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