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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803906
Report Date: 10/17/2022
Date Signed: 10/17/2022 06:45:50 PM

Document Has Been Signed on 10/17/2022 06:45 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: 3DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Anny Camerino, AdministratorTIME COMPLETED:
06:55 PM
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Licensing Program Analyst (LPA) K. Canela arrived unannounced for the purpose of following up on information received from North Bay Regional Center. LPA arrived to observe and address concerns received. During inspection, LPA observed deficiencies previously discussed during case management inspection (see report dated 09/12/2022).

LPA toured the facility and observed resident (R1)'s bedroom to have a strong urine smell. LPA discussed with Administrator regulation 87625(b)(3), that the facility must be free of odors.
Additionally LPA observed residents (R1, R2, R3) to have half bed-rails (photos taken). Additionally R3 had a lap belt in wheelchair. LPA discussed with Administrator that half bed-rails require an order from the resident's physician for assistance with mobility, because bed rails can be used as a form of restrain for residents. Administrator to request the approval of an exception for postural supports for R3's lap belt in wheelchair.

LPA observed individual (I1) in the facility providing care to resident (R2). LPA discovered I1 has been in the facility several times and has never signed in to the facility. Due to time restraints, LPA will return to review and issue citations warranted.


Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, (Title 22, Division 6) on the attached LIC809-D page. Failure to correct the deficiencies and/or repeat deficiencies within a 12- month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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 10/17/2022 06:45 PM - It Cannot Be Edited


Created By: Karina Canela On 10/17/2022 at 05:18 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: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited
CCR
87625(b)(3)

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87625 Managed Incontinence - (b)...the licensee shall be responsible for the following: (3) Ensuring ...that the facility remains free of odors from incontinence.

This requirement was not met as evidenced by:
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Administrator to train all staff submit copies of staff training on regulation 87626(b)(3). Training to include the date, time, duration, subject, instructor, staff's name and signature. Training to be submitted to Community Care Licensing (CCL) by POC due date 11/04/2022
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Based on observations and statements received from NBRC, Administrator did not ensure the regulation above due to Resident (R1)'s bedroom having a strong foul odor of urine. This is a potential personal rights and health risk to residents in care.
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Type B
10/21/2022
Section Cited
CCR87608(5)(A)

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87608 Postural Supports: (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement was not met as evidenced by:
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Administrator to remove half bed-rails from all resident's beds and submit pictures to LPA as proof of correction by 10/24/22. Administrator to obtain doctor's orders for half bed rails (for assistance with mobility) as required to have half bed-rails in place. Doctor's orders to be submitted to CCL by 11/04/2022
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Based on observations, statement and review of facility documents, Administrator did not ensure the regulation above due to Resident (R1, R2, R3) having half bed-rails without a doctor's order for assistance with mobility. R3 has a lapbelt in wheelchair. This is a potential personal rights, safety, and health risk to residents in care.
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Additionally, Administrator shall request an exception for the lap belt for R3's wheelchair & include supporting documentation (Doctor's order, LIC602, pre-appraisal, and any other supporting documentation such as discharge paperwork). submit exception by 10/24/2022
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: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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