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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804005
Report Date: 01/26/2023
Date Signed: 01/27/2023 09:54:37 AM

Document Has Been Signed on 01/27/2023 09:54 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:
01/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dinah Belandres and Licensee Rose DeveraTIME COMPLETED:
04:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct a Case Management visit and review resident R1's room #3 that was recently approved to be used for bedridden by the Vallejo Fire department. LPA will update the facility license to reflect changes. This facility is vendor by North Bay Regional Center.
Licensee Rose Devera arrived towards the end of the visit and LPA went over visit observations. LPA consulted with facility and reminded them to not put any items near any doors, so that doors can open to their full potential for fire safety reasons. During the visit, the small box was removed and facility was advised of the regulation and citations that may be issued, along with civil penalty fines if noncompliance continues.
During todays visit LPA reviewed food in the refrigerator and confirmed the dishwasher and oven were not properly working. LPA was notified of facility issues and LPA arrived to the facility to go over the concerns.
LPA observed staff bedroom not locked and there were prescription medication accessible and a bottle of cleaner in master bedroom bathroom and citations were issued.

LPA requested facility to send in all hospital discharge records for resident R1. LPA went over facility requirements regarding R1 and R2's care.
Facility to send in care plans for both R1 and R2.

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.

Exit interview conducted with Rose Devera, Licensee/Administrator. This report was emailed to facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/27/2023 09:54 AM - It Cannot Be Edited


Created By: Araceli Canela On 01/26/2023 at 03:26 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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
87705(f)(2)

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Care of Persons with Dementia 87705(f)(2) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Facility to send in written plan and staff training to ensure they are following regulation. Plan to include how they will make these items inaccessible to residents.
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This requirement was not met. During todays inspection, LPA observed the staff bedroom open, staff do not lock it- and LPA observed a bottle of staff prescription medication accessible. Bathroom in master bedroom also had a bottle of cleaner accessible. This is an immediate risk o the health & Safety of residents in care.
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POC due date: 1/28/2023
Type B
02/20/2023
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Facility to send in written plan they understand the facility and all appliances needed for the day to day operation are operational. Proof of items corrected to LPA
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This requirement was not met. During todays visit. LPA observed the facilities dishwasher and oven are not operational
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By POC date 2/20/2023

Attention : 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: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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