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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804154
Report Date: 10/24/2023
Date Signed: 10/24/2023 01:10:18 PM

Document Has Been Signed on 10/24/2023 01:10 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
SANTA ROSA RO, 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) 864-6683
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
10/24/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Julieta De Jesus, Caregiver TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Post-Licensing Inspection. There are currently 6 residents at the facility. There were 2 staff on duty at the time of inspection. Caregiver Dinah Belandres arrived at 9:45AM and Administrator Rose Devera arrived at 10:00AM.
The facility was clean and well-organized, and a comfortable temperature. All signage was up and in a highly visible location. One resident was resting in the living room, supervised. The other resident were resting in there bedrooms with a family member visiting in bedroom #3.

The kitchen was well stocked with perishable and non-perishable food items, as specified in Title 22. Opened containers will need to be labeled and dated. The facility was a comfortable temperature. Residents were clean and dressed appropriately. The fire extinguisher was accessible and fully charged last serviced on 06/13/2023. Carbon monoxide (1) and smoke detectors (8) alarms were tested and operational. Medications were locked and inaccessible to residents and unauthorized persons. Bathrooms were clean and equipped with hand grips and non-slip mats.

Inspection of 2 out of 2 resident files showed that Admissions Agreements and Physician's Reports were up to date. 2 out of 2 staff files showed that staff are up to date on training and have first aid and CPR.

Deficiencies observed during inspection:
LPA observed unlocked chemicals under kitchen sink with lose lock
LPA observed unlocked sharps (scissors and knife)
LPA observed unlocked laundry detergent and fabric softener
LPA observed a wheelbarrow with tools (saw/hedge cutter/pliers)
LPA observed water temperature 134.7 and 132.4 in residents bathrooms
LPA observed staff not fingerprinted and not assigned to the facility

Continue on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVING HEARTS CARE HOME 111
FACILITY NUMBER: 486804154
VISIT DATE: 10/24/2023
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Continue from LIC809



Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties.

Exit interview was conducted with the Administrator and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 10/24/2023 01:10 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/24/2023 at 12:20 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 111
FACILITY NUMBER: 486804154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87309(a)

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87309(a) STORAGE SPACE - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by:
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Administrator failed to ensure chemicals and sharps were kept secured and inaccessible to residents in care.
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unlocked chemicals accessible to residents. In addition, LPA found a knife and a pair of scissors located in an unlocked kitchen drawer. Unlocked cleaning supplies in bathroom, laundry room and under kitchen sink. Wheelbarrow with tools in backyard all accessible to residents in care. This poses as an immediate health and safety risk to residents in care.
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Administrator agrees to read and understand the regulation and create a safety checklist for staff to complete and signage posted in the facility to ensure future compliance.
Copy of safety checklist and photos of signage submitted to CCL by POC due date 10/26/2023.
Type A
10/25/2023
Section Cited
CCR87303(e)(2)

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(e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Administrator to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature is within regulation by POC date of 10/25/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 10/31/2023.
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Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 2 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA observed that hot water temperatures were 134.7.degrees F and 132.4 degrees F.
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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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


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Document Has Been Signed on 10/24/2023 01:10 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/24/2023 at 12:36 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 111
FACILITY NUMBER: 486804154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering...all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.

This requirement is not met as evidenced by:
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Administrator agrees to submit plan to ensure all individual are finger print cleared before working in the facility, submit to CCL by POC 10/26/2023. Administrator agrees to ensure S1 finger prints are cleared before returning to work in facility.
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Based on LPA record review the faciltiy failed to ensure S1 have a finger print clearance before working in the faciltiy which poses an immediate health and safety risk to clients in care.
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***Civil Penalty in the amount of $100 was assessed due to facility failing to obtain finger print clearance for S1.

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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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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