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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804154
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:49:41 PM

Document Has Been Signed on 05/04/2023 12:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LOVING HEARTS CARE HOME 111FACILITY NUMBER:
486804154
ADMINISTRATOR:DEVERA, ROSE MARIE B.FACILITY TYPE:
740
ADDRESS:702 MUSTANG CTTELEPHONE:
(707) 759-5239
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rose Devera, ApplicantTIME COMPLETED:
01:01 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced for the purpose of conducting a pre-licensing inspection on 05/04/2023 at Loving Hearts Care Home III.
LPA met with applicant Rose Devera, who will be the Administrator once the facility is approved for licensure. The facility has a fire clearance approval from the City of Fairfield Fire Department for a total capacity of 6 non-ambulatory. The facility does not have approval to accept or retain bedridden residents at this time. Applicant understands they must request and obtain bedridden room clearance from Community Care Licensing and the Fire Department prior to accepting bedridden residents. Bedroom #1 is approved for staff use. Facility will operate with live-in staffing and Licensee will ensure sufficient staffing at all times. Licensee understands staff or any person may not sleep in the room located in the garage.

During today’s visit LPA observed the following items:
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· Food supply was within regulation
· 2 Fire Extinguisher charged and serviced on 12/19/2022
· 9 hardwired smoke detectors and 1 carbon monoxide detector, were tested and observed operational
· Complete first aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Required furnishings in 5 of 5 resident bedrooms; staff bedroom was also inspected.

The Component III Orientation was completed.
Pre-licensing is complete with no corrections needed.
LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
No deficiencies cited
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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