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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804005
Report Date: 11/17/2022
Date Signed: 11/18/2022 09:44:40 AM

Document Has Been Signed on 11/18/2022 09:44 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rose DeveraTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, Linda Ramos. Administrator/Licensee Rose Devera arrived a few minutes later. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

Upon arrival, LPA observed that facility has Covid posters on the front door. LPA discussed visitation procedures with administrator, documenting & screening questions. Once inside the facility, LPA observed that facility has a sign-in for visitors, screening area with PPE . Staff wear masks inside the facility. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms, but no paper towels. Facility was a comfortable temperature. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day.

Facility staff have been trained on PPE. Facility has submitted their Covid-19 Mitigation Plan and it was approved. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication.

LPA observed the, "if you see something say something" complaint poster, but the poster is not the required size 20"x26". Facility will need to get and post the correct size, failure to correct will result in citation being issued.

Continue report See LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVING HEARTS CARE HOME II
FACILITY NUMBER: 486804005
VISIT DATE: 11/17/2022
NARRATIVE
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LPA requested the following updated records to be submitted to Community Care Licensing by 12/15/2022: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), LIC 9020 Register of Facility ResidentsLiability Insurance Certificate and Emergency Disaster Plan (LIC610E).

In addition, facility to send in the following information to LPA Araceli Canela by 11/21/2022: current facility sketch , correcting size of rooms, use of room by staff or residents, ambulatory, non -ambulatory or bedridden use. Facility to identify all rooms on sketch and use of room in garage. Facility to also provide current Administrator information and copy of Administrator certificate.

During today's visit staff S1 had a fingerprint clearance, but was not associated to the facility as required. Staff S1 did not have a current health screeing and proof of negative TB test.

LPA consulted regarding all the items that are being placed behind doors that may prevent exit doors to open properly and requested facility to move items during the inspection. Facility understands that this may be a fire safety violation and result in citations and civil penalties.
LPA also consulted regarding a front door deck piece of wood that felt loose and will need to be secured, firm and in good condition. LPA also requested facility to review right side of yard where a couple of bricks are sticking a little higher than the others and could be a tripping hazard or will not allow a wheel chair to go through easily. Facility to notify LPA of corrected status.

Deficiencies 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. Appeal rights were provided.

A civil penalty was assessed during todays visit for $100.00 for S1 not being associated to this facility.

Exit interview conducted with Rose Devera, Licensee/Administrator. This report was emailed to facility during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2022 09:44 AM - It Cannot Be Edited


Created By: Araceli Canela On 11/17/2022 at 03:14 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: LOVING HEARTS CARE HOME II
FACILITY NUMBER: 486804005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff file for S1, the licensee did not comply with the section cited above in 1 0f 2 count. S1 s file had a heakth screening dated 2016 and not withing 1 year of hire ,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Facility to send in proof of staff S1 current health screening and negative TB test. Faciklity to submitt written plan they understand regulation requirements and self certification all staff have the required Health screening record in file. POIC due 12/15/2022 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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/18/2022 09:44 AM - It Cannot Be Edited


Created By: Araceli Canela On 11/17/2022 at 03:14 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: LOVING HEARTS CARE HOME II
FACILITY NUMBER: 486804005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) 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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection and record reviewed staff S1 was fingerprint cleared but was not associated to this facility. The licensee did not comply with the section cited above in 1 out of 5 staff clearances/associattions to this facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2022
Plan of Correction
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Facility faxed the required forms to CCL during the inspection. Facility to send in written statement they understand regulation requirements and how they will ensure all staff have the required association to this facilty. written plan POC due 11/21/2022 attention LPA Canela
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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