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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804005
Report Date: 10/21/2021
Date Signed: 10/22/2021 12:25:44 PM

Document Has Been Signed on 10/22/2021 12:25 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:LOVING HEARTS CARE HOME IIFACILITY NUMBER:
486804005
ADMINISTRATOR:DATUIN, LUISAFACILITY TYPE:
740
ADDRESS:201 GREENMONT DRTELEPHONE:
(707) 864-6683
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rose Devera, ApplicantTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) A. Canela conducted thisLoving Hearts Care Home II pre-licensing inspection on 10/21/2021, for this change of ownership application. LPA met with applicant Rose Devera, and Luisa Datuin, who will be the Administrator for LOVING HEARTS CARE HOME II. The facility received a fire clearance approval from the Vallejo Fire Department on 7/13/2021 for a total of 6 Non-ambulatory residents. Applicant will ensure sufficient staffing at all times. The facility is one level home with 5 bedrooms , of which 4 bedrooms may be used for residents and 1 bedroom used for staff. There are 2 full bathrooms, living room, dining room, kitchen, laundry room and garage. The garage has a room that is used as an office and two sofas that facility states is used for staff to take a break and facility understands the garage is not approved for sleeping. The staffs bedroom has two beds and will be used for sleeping.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance
· Lockable separate cabinets for medications, toxin, and knives.
· All exits were unobstructed
· 6 smoke and 2 carbon monoxide detectors, which were all operational.
· First Aid kit and flashlights for emergency lighting.
· Supply of linens, paper products, and hygiene supplies available.
· Non-slip mat and grab bars in bathrooms.
· Fire Extinguisher charged and serviced 07/1/2021
· Required facility postings were observed
· The water temperature was tested during inspection and within regulation of 105-120 Degrees F.
· LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 5 residents.

Component III Orientation was completed with Applicant Rose Devera. Pre-Licensing is complete, LPA will notify Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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