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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700678
Report Date: 01/07/2022
Date Signed: 01/10/2022 10:56:01 AM

Document Has Been Signed on 01/10/2022 10:56 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LOVING CARE SENIOR LIVING IIFACILITY NUMBER:
342700678
ADMINISTRATOR:RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:4021 FAIRWOOD WAYTELEPHONE:
(916) 944-4969
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
01/07/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kelly Conley, House Manager TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Kelly Conley, manager, and explained purpose of inspection. Caregivers, Elena Bravo and Tammy Parrel, were also present. All staff were wearing a mask. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, confirmed there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and was requested to do so also upon entering the facility. The following Personal Protective Equipment (PPE) was worn: N95 Mask. LPA observed all (6) residents to be napping during today's inspection.

LPA and Manager toured and observed the facility to ensure the health and safety of residents in care. Areas toured include, but are not limited to: common areas, (6) private bedrooms, (2) bathrooms, dining room and kitchen. LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supplies for 90+days on hand. Toxins, sharps and medications are appropriately secured. In the areas toured, there were no immediate health, safety, or personal rights violations observed. LPA and manager completed the infection control domain and facility was found to be in compliance. LPA's observed required postings in the facility. LPA's and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40 issued 8/27/2021. LPA's observed current Administrator certificate posted Inside temperature was observed to. be 75* F. Extinguisher last serviced 9/1/2021.

LPA was previously provided a completed LIC500, LIC610E and liability insurance on/around 8/31/2021 following last annual inspection.

There are no deficiencies cited during today's inspection. Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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