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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801597
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:20:26 PM

Document Has Been Signed on 04/14/2022 04:20 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A LOVING HEART SENIOR CAREFACILITY NUMBER:
565801597
ADMINISTRATOR:DIORENA ROCK/ MICHEAL V.FACILITY TYPE:
740
ADDRESS:28 WALES STREETTELEPHONE:
(805) 230-3818
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:47 PM
MET WITH:Diorena RockTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20211116133659). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

During the course of the investigation, interviews conducted revealed that Resident #1 (R1) was transported to the hospital in July 2021. However, no incident report was provided to Community Care Licensing (CCL). Additionally, on 12/08/2021 Incident Report from 11/24/2021 reporting a 36-hr blackout at the facility and Incident Report from 11/12/2021 reporting R1 was observed with bruising on their sacrum were not submitted timely within the seven (7) days of occurrence as required by the California Code of Regulations.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC809-D).



Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 04:20 PM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 04/14/2022 at 03:48 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/29/2022
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety, or health of any resident.

This requirement is not met as evidenced by:
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The Administrator has agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87211 and submit to CCL by 4/29/2022.
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Based on interviews and documents received, the licensee did not comply with the section cited above as one (1) incident report was never received and two (2) other incident reports were not received by CCL within 7 days of occurrence, which poses a potential health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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