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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801049
Report Date: 05/20/2024
Date Signed: 05/20/2024 05:13:05 PM

Document Has Been Signed on 05/20/2024 05:13 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/
DIRECTOR:		MANAHAN, TEODORAFACILITY TYPE:
740
ADDRESS:735 E. HANKS STTELEPHONE:
(626) 969-2411
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Teodora Manohan TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Teodora Manohon who assisted with visit.LPA explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 2 ambulatory and 4 non-ambulatory residents. There is one resident on hospice.

The facility is a single story structure located in a residential neighborhood. It consists of the following: (4) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining area, living room, attached garage. laundry area located in the garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked in the kitchen and in the garage and inaccessible to residents. There are 3 refrigerator in the garage. Smoke / Carbon monoxide detectors were in compliance and operational. Fire extinguisher located in the kitchen and fully charged. The common areas are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. The resident bathroom is clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Last emergency/ fire drill was conducted on 01/24. LPA reviewed residents files to confirm emergency contact is updated.


Continue 809C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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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: 05/20/2024
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Residents medications reviewed. Medications documented properly and stored appropriately. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA reviewed residents and staff records. 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: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
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