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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002913
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:19:11 PM

Document Has Been Signed on 09/19/2024 02:19 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:A LOVING ARM HOME LLCFACILITY NUMBER:
315002913
ADMINISTRATOR/
DIRECTOR:		INVIERNO, VERONICA R.FACILITY TYPE:
740
ADDRESS:409 GLIMMER PLACETELEPHONE:
(916) 872-0384
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Veronica Invierno, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to investigate a complaint. During the visit LPA met with Administrator Veronica Invierno.

During the complaint investigation LPA observed the following deficiencies:
  1. Through interviews and observation LPA found that a closet was being utilized at a caregiver room. In addition, LPA found a room was built in the garage and being used as a bedroom.
  2. R1 did not have an admission agreement.
  3. Administrator had a new care staff working at the facility and they had no fingerprint clearance.
  4. Administrator did not handle a situation with a resident appropriately. Which is referenced in the complaint investigation.
  5. Administrator has not informed R1's primary care physician of incident or sought any type of medical attention for R1.
Deficiencies have been cited on the 809-D. Civil penalties have been issues. Copy of report and appeal rights provided to Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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
Document Has Been Signed on 09/19/2024 02:19 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 09/19/2024 at 12:49 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING ARM HOME LLC
FACILITY NUMBER: 315002913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
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Administrator agrees to get C2 fingerprint cleared and associated prior to working at the facility again. Administrator to send into CCL a receipt showing fingerprints process was started for C2.
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Based on interview and file review, the licensee did not comply with the section cited above as LPA observed C2 to be working without a criminal clearance which poses an immediate health, safety risk to persons in care.
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Type A
09/20/2024
Section Cited
CCR87405(d)(1)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator agrees to complete a training from an outside agency on administrator qualifications. Copy of training that administrator has signed up for to be sent into CCL by 9/20/24.
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This requirement is not met as evidenced by: Based on interviews, the licensee did not take actions to provide appropriate care for resident in care which poses an immediate health, safety risk to persons in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/19/2024 02:19 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 09/19/2024 at 01:19 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING ARM HOME LLC
FACILITY NUMBER: 315002913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Administrator agrees to get the facility staff areas cleared by the fire department. Administrator understands if the staff areas are not cleared by fire department,
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This requirement is not met as evidenced by: Based on interviews and observation, licensee had staff using a closet as a staff room and storage area in the garage as a staff room which poses a potential health and personal rights risk to residents in care.
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then the areas can not have staff living in closet or garage area. Administrator to write a statement of understanding and send into CCL by 10/04/2024.
Type B
10/04/2024
Section Cited
CCR87507(a)

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87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
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Administrator agrees to have an admission agreement completed for R1. Administrator to send into CCL a copy of the complete and signed admission agreement for R1 by 10/04/24.
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This requirement is not met as evidenced by: Based on observations licensee did not have an admission agreement for R1 which poses a potential personal rights risk to residents in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/19/2024 02:19 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 09/19/2024 at 01:50 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING ARM HOME LLC
FACILITY NUMBER: 315002913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87466(b)

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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any
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Administrator to contact R1's physician and notify them of incident that occurred and a doctor appointment to be made. Administrator to provide LPA with R1's appointment date by 9/20/24.
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This requirement is not met as evidenced by: Based on interviews, licensee did not notify R1's physician of incident that occurred which poses an immediate health, safety risk to persons in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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