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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005581
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:11:01 PM

Document Has Been Signed on 05/30/2024 04:11 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LOVING CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
306005581
ADMINISTRATOR/
DIRECTOR:		VIJAY KANASEFACILITY TYPE:
740
ADDRESS:2622 W OLIVE AVETELEPHONE:
(657) 354-7340
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 6DATE:
05/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Vijay KanaseTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On May 31, 2024, at 1:03pm Licensing Program Analyst (LPA) Edward Kim arrived to complete the required 1-Year annual visit that was started May 23, 2024. LPA Kim was greeted and granted entry by staff, and explained the purpose of the visit. Administrator Vijay Kanase arrived at 1:46pm to join the visit.

During the visit, LPA Kim conducted an audit of staff files #4-#5, resident files #1-#3, all resident medications, three (3) resident interview, and four (4) staff interviews. The first aid kit was reviewed and contained all the required items.

Deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided Administrator Vijay Kanase.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 05/30/2024 04:11 PM - It Cannot Be Edited


Created By: Edward Kim On 05/30/2024 at 03:50 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOVING CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 306005581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (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 obsevation and record review, the licensee did not comply with the section cited above. LPA observed in Resident #1 (R1) The medical assessment indicates the R1 has dementia and the last medical assessment was April 21, 2023. This poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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The Licensee states they will send the updated medical assessment for R1 to CCLD via email to edward.kim@dss.ca.gov by June 7, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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