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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 08/29/2022
Date Signed: 08/29/2022 06:33:20 PM

Document Has Been Signed on 08/29/2022 06:33 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LUVINHOME,LLCFACILITY NUMBER:
486803906
ADMINISTRATOR:CAMERINO, ANNY K.FACILITY TYPE:
740
ADDRESS:974 SUFFOLK WAYTELEPHONE:
(707) 999-8276
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 2DATE:
08/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anny Camerino, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Canela arrived unannounced for the purpose of delivering citations for deficiencies observed. Community Care Licensing (CCL) received information of a COVID positive case at Luvinhome which occurred on 06/21/2022. CCL was notified of the case by an outside agency on 06/28/2022 and facility did not submit an incident report as required within the 7 days of occurrence.
Additionally, records reviewed and interviews conducted revealed staff have not received or are missing required training. 40 hours (initial) training to include, but not limited to:
    (1) Principles of good nutrition, good food preparation and storage, and menu planning.
    (2) Housekeeping and sanitation principles.
    (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
    (4) Knowledge required to safely assist with prescribed medications which are self-administered
      - Staff assisting with medications require 8 hours of in-service training on medication related issues
    (5) Dementia Training (8 hours)
    (6) Postural Supports, restricted conditions, and hospice care (4 hours)

During inspection, LPA & Administrator discussed annual staff training and regulation 87412 Personnel Records to be maintained in file at the facility for CCL review. LPA requested copies of documentation for surveillance testing of staff previously. On 06/29/2022 LPA received incomplete documentation for 1 of 4 staff. During this inspection, LPA requested Administrator send complete documentation of COVID-19 surveillance testing by 09/02/2022 close of business (5PM) to CCL for review.
Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Anny Camerino, Administrator whose signature below confirms receipt of report
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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Document Has Been Signed on 08/29/2022 06:33 PM - It Cannot Be Edited


Created By: Karina Canela On 08/29/2022 at 01:38 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LUVINHOME,LLC
FACILITY NUMBER: 486803906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
87411(c)

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87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:
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Administrator to have all staff receive required training and document for CCL review. Training to include the date, time, duration, subject, instructor, staff name and signature. Trainings to be submitted to Community Care Licensing (CCL) by POC due date 09/23/2022*
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Based on records reviewed and interviews conducted, Administrator did not ensure the regulation above as staff are missing or have not received required training. This is a potential health, safety and personal rights risk to residents in care.
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Type B
09/02/2022
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...
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 Administrator to submit a statement they understand the regulation and will be in future compliance. Administrator to submit statement of future compliance to CCL by POC due date 09/02/2022.
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This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, Administrator did not ensure the regulation above due to submitting on 06/30/2022. This is a potential health, safety and 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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