<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801049
Report Date: 06/15/2022
Date Signed: 06/15/2022 06:19:20 PM

Document Has Been Signed on 06/15/2022 06:19 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVING CARE HOMEFACILITY NUMBER:
197801049
ADMINISTRATOR:MANAHAN, TEODORAFACILITY TYPE:
740
ADDRESS:735 E. HANKS STTELEPHONE:
(626) 969-2411
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 3DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Administrator Teodora ManahanTIME COMPLETED:
06:15 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) Nune Margaryan conducted an annual required visit. LPA met with Administrator Teodora Manahan and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have three hospice residents. There is currently 2 resident on hospice. Facility serves dementia residents and has auditory devices in exit doors. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located at the entrance of facility. Sign in sheet, hand sanitizer, gloves and masks are available. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. All staff were observed to be wearing mask during this visit.
LPA toured the home and inspected (4) client bedrooms, (1) staff bedroom, (2) bathrooms, kitchen, dining room, living room, family room, and detached garage. There is a laundry area in the garage. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. Resident bedrooms were inspected. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Bathrooms have the required grabs bars and non-skid mat. The hot water was tested 107.9 degree which is within the required 105 - 120 degrees. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector in the living room area of the home. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and operating properly. Sharps are locked in a kitchen drawer and are inaccessible to clients. There is a fire extinguisher located in the kitchen and it is fully charged.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOVING CARE HOME
FACILITY NUMBER: 197801049
VISIT DATE: 06/15/2022
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
26
27
28
29
30
31
32
Cleaning supplies observed locked in the garage and inaccessible to residents. The common areas are clean and have the required furniture. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22.

LPA reviewed residents and staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA reviewed residents' medications. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was conducted with Administrator and a copy of this report was provided.



SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2