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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804005
Report Date: 11/13/2024
Date Signed: 11/18/2024 10:48:56 AM

Document Has Been Signed on 11/18/2024 10:48 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/
DIRECTOR:
BELANDRES,DINAHFACILITY TYPE:
740
ADDRESS:201 GREENMONT DRTELEPHONE:
(707) 864-6683
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:58 AM
MET WITH:Dinah Belandres, Administrator and Rose Deveral, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 11/13/2024, Licensing Program Analyst (LPA) A. Canela conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by care staff, Francisca Martinez. Administrator, Dina Belandres and licensee, Rose Devera arrived a few minutes later.

The facility is licensed for six non-ambulatory residents and a hospice waiver for three. The facility currently provides care for six residents, of which one is receiving hospice services.
LPA toured the facility with care staff and facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/11/2024. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Water at faucets accessible to residents was measured between 105 and 120 degrees which is within regulation.

Toxins, sharps and other items that could pose threat if readily available to residents were kept locked under the kitchen and bathroom sinks and within cabinets in the laundry room all of which were found to be secured. During inspection, LPA observed three storage sheds located in the side yard to also be locked and secured.

LPA reviewed two resident files and requested additional information regarding the shared room situation and verification that resident R1 and R2s personal rights are not being violated.

LPA will return and complete inspection due to time restraint

No citations issued at this time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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