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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002925
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:15:20 PM

Document Has Been Signed on 01/12/2023 01:15 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LOVING-KINDNESS CAREHOME LLCFACILITY NUMBER:
315002925
ADMINISTRATOR:NINOBLA, DERBBIEFACILITY TYPE:
740
ADDRESS:912 OAK RIDGE DRTELEPHONE:
(916) 297-7694
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 5DATE:
01/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Derbbie Ninobla- Administrator TIME COMPLETED:
01:15 PM
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On 01/12/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management Incident visit. LPA met with Administrator, Derbbie Ninobla, and explained the purpose of the visit.

The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 01/11/2023. The report indicates that Administrator observed R1 has not been eating for a few days, groaning, and showed signs of weakness. R1 notified Administrator they had chest pain. Administrator called for an ambulance and resident was transferred to the ER.

LPA interviewed Administrator regarding incident report. Administrator stated R1 has been transferred to the hospital about seven (7) times. Administrator stated R1 had a change of condition and the facility is unable to meet R1's needs. Administrator stated R1's Social Worker has been in contact and notified Administrator R1 will not be returning to the facility and will be placed at another facility. LPA request for Administrator to follow up with R1's Social Worker and find out where resident will be placed. LPA requested for R1's incident reports, physician's report, needs and services plan, and discharge medical documents.

At this time, deficiencies are not being cited.

Exit interview conducted and report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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