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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209262
Report Date: 12/05/2024
Date Signed: 12/12/2024 11:09:01 AM

Document Has Been Signed on 12/12/2024 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:LOVING HEART MANORFACILITY NUMBER:
277209262
ADMINISTRATOR/
DIRECTOR:		ESTAMO, JUANITO JR.FACILITY TYPE:
740
ADDRESS:745 CARMELITA DRIVETELEPHONE:
(831) 758-8121
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Licensee, Juanito EstamoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Juanito Estamo, Continual Administrator's Certification expires 03/05/2025. There are currently 5 residents who reside at this home and there is 1 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector. First Aid kit is on site and complete.

The facility could not provide Resident 1's hospice care plan. Resident 1 does not have required pre admission appraisal. LPA observed bleach under the sink in Resident 2's bedroom. LPA observed medications on the kitchen table accessible to residents. Resident 3's medication was not properly documented on the Centrally Stored Medication logs. Resident 3 does not have required annually updated medical assessment. Resident 3 did not have an updated Needs and Services plan. Staff 1 has no CPR first aid/ no 501 Employment application, no 503 Health Screening, no training on file. Fire extinguisher is not within the safety regulation period (5/2023.) LPA observed resident hallways bathroom water measures at 104 degrees.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Juanita Estamo, and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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Document Has Been Signed on 12/12/2024 11:09 AM - It Cannot Be Edited


Created By: Sarah Hurt On 12/05/2024 at 03:54 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
,
, CA

FACILITY NAME: LOVING HEART MANOR
FACILITY NUMBER: 277209262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. the licensee did not comply with the section cited above in LPA observed bleach in Resident 4's sink vanity, unlcoked and accessible to facility residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee will provide training to facility staff on proper storage of cleaning supplies, and submit to LPA by POC date of 12/06/2024.
Type A
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include 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 the Licensee could not provide hospice care plan for Resident 1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee will submit Resident 1's hospice care plan to LPA by POC date of 12/06/2024.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2024 11:09 AM - It Cannot Be Edited


Created By: Sarah Hurt On 12/05/2024 at 03:54 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
,
, CA

FACILITY NAME: LOVING HEART MANOR
FACILITY NUMBER: 277209262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(C)
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan.

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 the Licensee could not provide required Infection Control Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee will submit required nfection Control plan to LPA Hurt by POC date of 12/06/2024.
Type B
Section Cited
CCR
87303(a)(2)

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed water temperature in hallway bathroom to measure 104 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee will ensure facility water temperature measures between 105 and 120, and send proof to LPA by POC date of 12/19/2024.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/12/2024 11:09 AM - It Cannot Be Edited


Created By: Sarah Hurt On 12/05/2024 at 03:54 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
,
, CA

FACILITY NAME: LOVING HEART MANOR
FACILITY NUMBER: 277209262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 Resident 3 does not have current/ updated medical assesment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee will provide current/updated medical assesment for facility Resident 3 by POC date of 12/19/2024.
Type B
Section Cited
CCR
87465(b)(2)
Incidental Medical and Dental (a)
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed prescription medications on dining table, unlocked and accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee will conduct staff training on medication storage, and submit proof to LPA by POC date of 12/19/2024.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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