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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006220
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:41:27 PM

Document Has Been Signed on 03/12/2024 03:41 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:MARY'S LOVING CARE AFACILITY NUMBER:
306006220
ADMINISTRATOR:HAN, XUFACILITY TYPE:
740
ADDRESS:341A 16TH PLACETELEPHONE:
(646) 549-5035
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Xu Han You - Licensee/AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Administrator (AD) Xu Han’s Administrator certificate was posted on the wall and expires October 15, 2024.

Mary’s Loving Care A is a one-story community with four bedrooms and four bathrooms. The facility capacity is 6 and the census was 5 during today’s visit. Residents were observed in the living room watching TV or in their bedroom.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines.

Resident bathrooms were clean and organized. Hot water temperatures were measured in the range of 113.1 degrees Fahrenheit and 118.2 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms, and all grab bars were tightly secured to the wall. In Bathroom #1 LPA Haley observed a cabinet with a supply of clean linen.

In the kitchen knives and sharp objects are kept locked in a cabinet next to the refrigerator. Resident medications are kept locked in the same cabinet. All four burners on the stove were operational. Hazardous cleaning items were kept locked under the sink. A first aid kit with all the required elements is locked in a cabinet next to the refrigerator.

In the garage, an additional supply of hazardous cleaning items was observed on the shelves. An extra refrigerator was observed in the garage with a supply of perishable food supply that meets regulation requirements. A supply of nonperishable food items was observed on the shelves. An emergency supply of COVID items (surgical mask, gloves, sanitizer) was observed as well.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220
VISIT DATE: 03/12/2024
NARRATIVE
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Walkways were clear and free of obstruction. Additional cleaning supplies, an extra bedframe, mattress, and adult diapers were observed in the garage as well.

The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with tables and chairs was observed. The side exit gate is self closing and self latching.

Smoke detectors/Carbon monoxide detectors tested operational and were observed in all resident rooms, and the hallway. A fully charged fire extinguisher was observed on the floor in the living room area in between two resident rooms.

Emergency evacuation drill will be conducted this month and will continue to be conducted quarterly for staff on each shift.

Deficiencies are being cited as a result of todays visit.

An exit interview conducted, and a copy of this report was provided to Licensee/Administrator Xu Han.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2024 03:41 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/12/2024 at 02:48 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: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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S1 has been working in the facility since being hired in March of 2023 without a fingerprint clearance.
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Licensee/Administrator Xu Han will remove Staff 1 (S1) from the schedule and not allow the S1 back until fingerprinted, cleared, and associated to the facility roster. S1 left the facility during the visit. Licensee/Administrator will email LPA Haley an new LIC500 when S1 has been removed.
POC Due date: March 13, 2024 at 1:00PM
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/12/2024 03:41 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/12/2024 at 02:48 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: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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All staff files were incomplete and missing required documents.
Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee/Administrator Xu Han will completed all staff files and email LPA Haley the missing documents for each staff member.
POC due date: March 19, 2024 at 1:00PM
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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