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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804154
Report Date: 05/13/2024
Date Signed: 05/16/2024 09:40:25 AM

Document Has Been Signed on 05/16/2024 09:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LOVING HEARTS CARE HOME 111FACILITY NUMBER:
486804154
ADMINISTRATOR/
DIRECTOR:		DEVERA, ROSE MARIE B.FACILITY TYPE:
740
ADDRESS:702 MUSTANG CTTELEPHONE:
(707) 864-6683
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rose Marie B. Devera, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members Julie De Jesus and Frank Oboza. Licensee/Administrator, Rose Marie B. Devera was contacted and arrived during visit at approximately 10:15AM. Facility is a Licensed Residential Care Facility for the Elderly (RCFE) and serves residents with dementia. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 5 residents in care and 3 staff members on-site.

At approximately 9:50 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with staff members and Licensee/Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature. Carbon monoxide and smoke detectors were tested and found to be operational. Exits were observed as free from obstruction with the exception of one emergency exit in a shared resident room where a walker and commode were placed in front of the exit. LPA advised licensee per regulation, these exits are to be maintained free from obstruction. Licensee removed the items immediately. Facility's auditory signal was observed inactivated at facility entrance and inoperable in resident room on the sliding glass door emergency exit. Licensee had staff correct this during visit. Facility had emergency lighting.

Facility is a 1 story building with 5 resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of perishable foods as required by Title 22 Regulations, but both canned and dried non-perishable food items were observed by LPA to be expired. Licensee threw them away immediately and ordered more non-perishable foods during inspection. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. LPA observed hand towels in the common resident restroom and advised Licensee that only paper products are in compliance with regulation. Licensee removed the towels immediately. Toxins were observed to be stored inaccessible to residents except for a a can of Lysol observed in a drawer in the common resident bathroom and a bottle of isopropyl alcohol observed accessible on a shelf in the common living area. Licensee removed both items immediately.

Continued on 809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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 9
Document Has Been Signed on 05/16/2024 09:40 AM - It Cannot Be Edited


Created By: Julie Florio On 05/13/2024 at 03:01 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: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Licensee to submit proof of completion of the required training for all staff to CCL by the POC due date 6/12/2024.

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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 09:40 AM - It Cannot Be Edited


Created By: Julie Florio On 05/13/2024 at 03:01 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: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 medications spot checked which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Licensee to submit aelf-certification including signatures of each employee certifying their understanding of correct maintentance of centrally stored medication logs to CCL by the POC due date 6/12/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


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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: 05/13/2024
NARRATIVE
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Continued from LIC809...

Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Water temperatures in 2 of 2 resident bathrooms tested within the allowable range of 105 degrees F and 120 degrees F per regulation. LPA observed a locked shed in the backyard which is strictly used for equipment storage. Medications were observed to be centrally stored and locked.

At approximately 11:15, LPA reviewed 5 staff and 5 resident files. LPA observed 5 of 5 staff missing the required initial medication training and were deficient 6 hours of dementia training and 4 hours of Hospice, Postural Supports, or Restricted Conditions Training. All staff have the required First Aid training and all but 1 have the required CPR training. Licensee to submit proof of CPR training for the remaining staff member to CCL.

All 5 of 5 resident files has all the required paperwork, including current Individual Service Plans, however 4 of 5 were not signed by the resident or their responsible party. Licensee informed LPA that each has been reviewed with the respective resident and/or their responsible party. LPA advised Licensee to have these signed.

LPA observed the centrally stored medication log to be maintained inaccurately with dates and directions not matching the prescription label on the bottle. LPA advised Licensee that all staff need to be trained on proper medication documentation, tracking and administration, to include not signing off on administrations prior to actually administering the dose.

Licensee to submit updates of the following documents by 6/12/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E), Hospice Care Plan; control of property (lease); a copy of Liability Insurance; fire sketch; copy of fire clearance; .

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview was conducted with Licensee/Administrator. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 09:40 AM - It Cannot Be Edited


Created By: Julie Florio On 05/13/2024 at 04:08 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: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff records reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Licensee to submit proof of completion of the required medication training for all staff to CCL by the POC due date 6/12/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


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Document Has Been Signed on 05/16/2024 09:40 AM - It Cannot Be Edited


Created By: Julie Florio On 05/13/2024 at 04:16 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: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 exits which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee corrected the deficiency with LPA present. All auditory signals are now operable and properly functioning.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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