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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005841
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:01:31 PM

Document Has Been Signed on 12/19/2023 03:01 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LOVING HOME CAREFACILITY NUMBER:
306005841
ADMINISTRATOR:LE, TINFACILITY TYPE:
740
ADDRESS:13402 HOOVER ST.TELEPHONE:
(714) 600-7083
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 6DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Tin Le, Licensee/AdministratorTIME COMPLETED:
03:10 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
 On today's date, LPA Quiroz conducted an unannounced Case Management-Deficiencies visit in conjunction to complaint investigation follow up for complaint control #22-AS-20210701151949. LPA Quiroz met with Licensee/Administrator (L/AD) Tin Le and discussed the purpose of today's visit.
On today's date, to assist with complaint investigation for complaint control #22-AS-20210701151949, LPA Quiroz requested resident records for Resident 1 (R1). (L/AD) Tin Le indicated "I don't have the original documents, the resident was here only less than 2 weeks and the Family never returned the packet back to me, I only have the LIC 602 in an email." LPA Quiroz not able to review the following requested documents for (R1) during today's date: Admission Agreement, Pre- Appraisal, Needs and Services Plan, Identification Form due to R1 records not being available on site or in centralized location. (L/AD) Tin Le concluded "We don't have them."
LPA Quiroz provided consultation on the following California Code of Regulation to (L/AD) Tin Le:
Resident Records-87506(e): Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

Facility Cited during today's visit (See LIC 809-D). Plan of correction was cleared during today's visit.

LPA Quiroz conducted an exit interview with (L/AD) Tin Le and provided a copy of this report, Appeal Rights, LIC 809-D, Cleared POC Letter and LIC 811- Confidential Names at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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
Document Has Been Signed on 12/19/2023 03:01 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 12/19/2023 at 01:31 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 HOME CARE
FACILITY NUMBER: 306005841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87506(e)

1
2
3
4
5
6
7
Resident Records-87506(e): Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
(L/AD) Tin Le agreed to read, review and understand CCR 87506 and maintain in compliance with resident records prior to admitting resident into facility. (L/AD) Tin Le submitted proof of understanding of CCR 87506 on today's date.
8
9
10
11
12
13
14
Based on interview with (L/AD) Tin Le regarding investigation of complaint control #22-AS-20210701151949, LPA Quiroz requested resident records for Resident 1 (R1). (L/AD) Tin Le indicated "I don't have the original documents, the resident was here only CONTINUED...
8
9
10
11
12
13
14
CONT... less than 2 weeks and the Family never returned the packet back to me." LPA Quiroz not able to review R1s records during today's date. (L/AD) Tin Le concluded, "We don't have them." This poses a potential risk to residents in care.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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