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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005841
Report Date: 04/13/2024
Date Signed: 04/13/2024 01:25:36 PM

Document Has Been Signed on 04/13/2024 01:25 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 HOME CAREFACILITY NUMBER:
306005841
ADMINISTRATOR/
DIRECTOR:		LE, TINFACILITY TYPE:
740
ADDRESS:13402 HOOVER ST.TELEPHONE:
(714) 600-7083
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 5DATE:
04/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Staff on duty - Patricia CanoTIME VISIT/
INSPECTION COMPLETED:
01:32 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted facility administrator (AD) Tin Le about visit, however was unable to be present during time of visit, and provided consent for staff on duty (S1) Patricia Cano to receive and sign report. LPA observed the Administrator's Certificate for Tin Le which expires on 11/28/24.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 residents, of which 4 may be non-ambulatory and 2 may be ambulatory. Facility has a hospice waiver for 4 residents. There are a total of 5 bedrooms, of which 4 are private resident rooms, and 1 shared resident room. LPA observed that the facility has a space in the garage designated for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms and were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 111.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.


SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOVING HOME CARE
FACILITY NUMBER: 306005841
VISIT DATE: 04/13/2024
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the kitchen, garage and in a storage closet. LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were locked in a cabinet and made inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with S1 Cano.

A copy of this report was explained, and provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2024
LIC809 (FAS) - (06/04)
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