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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803912
Report Date: 10/27/2021
Date Signed: 10/28/2021 02:32:20 PM

Document Has Been Signed on 10/28/2021 02:32 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:A LOVING LIVING HOME CAREFACILITY NUMBER:
486803912
ADMINISTRATOR:LOVELYN HOJILLAFACILITY TYPE:
740
ADDRESS:224 LOCH LOMOND DRIVETELEPHONE:
(707) 469-9029
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Lovelyn HojillaTIME COMPLETED:
05:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management- inspection and met with staff Suzette Hojilla, Imelda Good and Jon Cafuir; Administrator, Lovelyn Hojilla was not available and was said to be at work, during this visit. The purpose of this case management visit was to follow up on self reported incident report that was submitted to Community Care Licensing (CCL) regarding resident R1.

LPA went over incident details and requested copies of resident R1's file.
On September 27, 2021 at about 10:00pm R1 sustained a fall in their room. It was reported staff were assisting other residents when they heard a noise and found R1 on the floor in their room. LPA is gathering additional information regarding the procedures facility took regarding this incident. The resident was sent to the hospital the next day, 9/28/2921 and diagnosed with a Femur Fracture and Lesser Trochanter medially displaced; R1 had surgery on 9/29/2021. The facility submitted a request for a Hospice exception for resident and later withdrew the request, when R1 passed away on 10/20/2021. During today's visit LPA received information R1 returned to this facility on Hospice services on 10/18/2021, aspirated and passed away on 10/20/2021. A hospice exception was never approved or granted to the facility.
LPA will review information and will follow up with facility, once additional information is gathered and reviewed.

During today's visit LPA found that tenant/staff S4, has fingerprint clearance, S4 is not associated to this facility as required. LPA reminded facility, that staff must wear a mouth covering while at the facility, staff S1 and S2 were not wearing a mask upon LPAs arrival. LPA also observed the facility auditory devices on the two sliding doors were not working properly and not completely turned/plugged on; review of records indicate there are at least 4 residents with Dementia.

Continue report see LIC809-C and LIC809-D for deficiencies observed and cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/28/2021 02:32 PM - It Cannot Be Edited


Created By: Araceli Canela On 10/27/2021 at 03:01 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: A LOVING LIVING HOME CARE
FACILITY NUMBER: 486803912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
87355(e)(2)

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87355(e)(2) 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:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Facility to send in written statement they understand regulation and requirements.
Facility stated they processed paperwork to associate S4 but do not know what happened.
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This requirement is not met as evidenced by: During today's visit tenant/staff S4 had fingerprint clearance but was not associated to this facility. This is an immediate risk to the residents in care.
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 Facility went into Guardian and processed the paperwork for S4.
POC due date 10/28/2021
$100.00 civil penalty assessed for S4 not associated.
Type B
10/28/2021
Section Cited
CCR87705(j)

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87705(j) Care of Persons with Dementia .The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Facility to send in written plan on how they will ensure alarms are always turned on and operational. Proof of staff training
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This requirement was not met as evidenced by: during todays visit and facility tour, the sliding door alarm in resident R3 and R4 was not operational. The dining slide door alarm was also not operational. This is a potential risk to residents in care.
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POC due date 10/28/2021 to LPA Araceli Canela.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2021 02:32 PM - It Cannot Be Edited


Created By: Araceli Canela On 10/27/2021 at 03:01 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: A LOVING LIVING HOME CARE
FACILITY NUMBER: 486803912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2021
Section Cited
CCR
87705(c)(5)

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 87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Facility agrees to send in proof of current medical assessment for resident R2 and statement they understand regulation.
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This requirement was not met as evidenced by: during record review, resident R2 did not have a current Physician report- last report in file was dated 9/17/20220 and not within regulation. This is a potential risk to the health and safety of residents in care
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POC due date 11/26/2021 to LPA Araceli Canela

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: A LOVING LIVING HOME CARE
FACILITY NUMBER: 486803912
VISIT DATE: 10/27/2021
NARRATIVE
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Physician report for resident R2 is dated 9/22/2020 and not done yearly as required. LPA informed facility, the administrator must be present at least 20% of the time during business hours. LPA consulted regarding requirements for a facility if a Hospice resident becomes bedridden. Facility does not have bedridden approval, facility will need to immediately call CCL and a Fire Clearance will need to be approved by the fire department for bedridden room. Facility to get additional records and forms needed to be submitted if there is ever a need. LPA also consulted regarding facility not able to admit a resident who requires Hospice services, if they do not have approval or number of Hospice residents exceed. LPA will follow up with facility regarding this matter. Facility not to accept any residents who are bedridden unless written approval has been granted from Fire department and CCL. LPA also reminded facility of having complete staff records and facility scheduled activities.

The following deficiencies were observed (see LIC 809-C) and cited 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. A civil penalty in the amount of $100.00 was assessed today for staff S4 not being properly associated to this facility.
Exit interview conducted and appeal of rights and this report will be emailed to facility due to computer problems. LPA informed administrator, due to computer issues, LPA will email report that LPA was unable to obtain signature.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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