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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804154
Report Date: 05/24/2024
Date Signed: 05/24/2024 01:19:31 PM

Document Has Been Signed on 05/24/2024 01:19 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/
DIRECTOR:		DEVERA, ROSE MARIE B.FACILITY TYPE:
740
ADDRESS:702 MUSTANG CTTELEPHONE:
(707) 864-6683
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Dinah Belandres, Caregiver & Rose Marie B. Devera, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced at facility to conduct a case management and was greeted by caregivers, Julieta D. De Jesus and Joy Awa . Caregivers attempted to reach Licensee/Administrator via phone. Caregiver, Dinah Belandres arrived at 9:45 AM and was able to reach Licensee/Administrator via phone at 9:50. LPA spoke with Licensee/Administrator, informed Licensee/Administrator the purpose of the visit is to follow up on an a self-reported incident report of resident (R1) elopement submitted to Community Care Licensing (CCL) on 5/16/2024. Licensee/Administrator gave verbal authorization for LPA to proceed with the visit and Licensee/Administrator would arrive to facility as soon as possible.

CCL received a self-reported incident report that occurred at approximately 8:45 AM on the morning of 5/15/2024. It was reported at approximately 8:55 PM on the evening of 5/16/2024 by Licensee/Administrator that R1 told the caregivers that he wanted to go for a walk around the backyard as he does this every morning for about 30 minutes. Licensee/Administrator reported that when caregivers checked on him, they didn't find him and observed the backyard gate to the front of the house was open. Licensee/Administrator reported that caregivers looked for him for approximately 30 minutes and notified Licensee/Administrator who then called 911. Licensee/Adminstrator reports that the local police found R1 on the next block and reported that R1 claimed to have stumbled on a small rock which caused him to fall and he complained of shoulder pain. Licensee/Adminstrator reported that R1 was then taken to Kaiser Vacaville Emergency Room and R1's signficant other was contacted

Per R1's Physician’s Report (LIC602) dated 04/24/2024, R1 has dementia and is unable to leave facility unassisted. LPA reviewed R1's Appraisal/Needs and Service Plan (LIC625) and noted that it needs to be updated to include increased supervision of R1 throughout the day and that he is not to be in the backyard or outside of the facility without supervision. Facility is being cited for not providing the services necessary to meet resident needs as evidenced by a lack of supervision while in the backyard which led to elopement and injury (see LIC809-D).

Continued on LIC809-C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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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: 05/24/2024
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Continued from LIC809...

During visit, LPA interviewed R1 who expressed a desire for more interaction and would like daily activities to occur in facility. LPA did not witness any activities happening during visit, and upon reviewing the activities schedule, determined that it does not truthfully and accurately reflect daily activities that occur in the facility. LPA advised Licensee/Administrator and staff of more appropriate, realistic, and achievable daily activities that take the needs of the residents in care into consideration. LPA is requesting an updated activities schedule and proof they are occurring as scheduled (see LIC809-D, Plan of Correction).

A copy of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:



R1s Hospital Discharge Instructions and Documents

The following deficiencies were observed (see LIC 809-D) and 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. Exit interview conducted with Licensee/Administrator and appeal of rights provided. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2024 01:19 PM - It Cannot Be Edited


Created By: Julie Florio On 05/24/2024 at 12:42 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: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87411(a)

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Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [....]
Based on record review, self-incident report, and interviews
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Licensee/Administrator to submit and updated Appraisal/Needs and Service Plan (LIC625) for R1 to include increased supervision by POC due date 6/3/2024.

Licensee/Administrator to provide an updated activity schedule with some activities
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conducted with R1, caregivers, and Licensee/Administrator, R1 eloped without staff knowledge. The facility did not comply w/section above to address behaviors such as wondering for R1 which poses an immediate Health, Safety risk to residents in care.
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specific to R1’s needs and proof that these activities are occurring as scheduled; proof of elopement training for staff; and submit LIC9098 that the staff understand the regulation by POC due date 6/13/2024.

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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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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