Forever Love Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Annual Required visit for this facility. LPA met with the administrator, Mark Belmonte and explained the reason for the visit. The facility is licensed for a total capacity of six (06) with fire clearance for five (05) non-ambulatory residents, and one (01) bedridden. At approximately 12:00 p.m., LPA and administrator toured the physical plant of the facility inside and out and the following was observed: At entry LPA observed a sign in log for visitors and a digital thermometer affixed to the wall. LPA observed appropriate postings. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility, properly stored. Knives and sharps were stored in a locked kitchen drawer. LPA observed cleaning supplies locked under the kitchen sink cabinet. Centrally stored medication was observed locked in a kitchen cabinet. One (01) fire extinguisher in the kitchen was observed fully charged with service date 07/12/2024. Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards and fenced in. No bodies of water observed. There are dual carbon monoxide and smoke detectors that are hard wired and interconnected though out the facility. Administrator tested detectors at 12:25 p.m., and LPA observed detectors functioning properly. Fire door closed when test was conducted. (Continue to LIC809) (Continued from LIC809) Bedrooms: Five (5) bedrooms are designated for resident use one (1) of which may be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient storage and lighting. One (1) hallway cabinet was observed to have first aid kit and first aid kit supplies. Another closet stored extra linens and towels. Bathrooms: There are three (3) bathrooms available for residents' use. Bathrooms were supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured from two (02) bathrooms at 12:30 p.m., and read 111 degrees Fahrenheit, within regulation. Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches and arm chairs where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. During visit LPA observed residents sitting in the living room with family visitors. LPA observed two (2) portable telephones accessible to residents. Laundry and Garage: The laundry room is located in the hallway by the residents' rooms and leads to the attached garage. Laundry room was observed locked. Detergents and cleaning supplies were observed locked in the laundry room. LPA observed a freezer and a refrigerator in the garage with extra food. Resident, Staff, and Facility Files: At 12:57 p.m., LPA conducted a file review of five (5) out of five (5) resident records to ensure compliance of licensing forms. LPA also conducted a file review of two (2) staff records to ensure forms and training are up to date and in compliance with licensing forms. LPA reviewed facility's liability insurance and emergency disaster plan (LIC610E.) Facility had not documented an emergency disaster drill for their last quarter. Medications: At 2:27 p.m., LPA reviewed Medication and Medication Records. Medications were reviewed for proper storage and documentation. Facility also maintains a Medication Administration Record (MAR). Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jul 8, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit for this facility. LPA met with the administrator, Mark Belmont and administrator designee Mylene Veatch and explained the reason for the visit. The facility is licensed for a total capacity of 6 with fire clearance for five (5) non-ambulatory residents, and one (1) bedridden. At approximately 9:50 a.m. LPA and administrator tour the physical plant of the facility and the following was observed: Bedrooms: There are six (6) total bedrooms one of which is for staff use only. Five (5) bedrooms are designated for resident use one (1) of which may be shared. Bedroom are currently private. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed various hallway closets and cabinets used as storage for extra facility supplies. In one (1) of the supply closets LPA observed a fully supplied first aid kit. Auditory alarms were observed on Exit doors and were functioning properly. Bathrooms: There are three (3) bathrooms. One (1) bathroom is located in a bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured at 10:15 a.m. and read between 117 and 118.5 degrees Fahrenheit within regulation. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. LPA observed fresh fruit and sealed snacks located at the kitchen counter and on a side table in the common area for residents. Knives and sharps were stored in a locked kitchen drawer. LPA observed cleaning supplies locked under the kitchen sink cabinet. (Continued on LIC809-C) Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches and arm chairs where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. During visit LPA observed residents playing cards and scrabble. LPA observed two (2) telephones accessible to residents. Laundry and Garage: The laundry room is located in the hallway by the residents' rooms and leads to the attached garage. Laundry room was observed locked. Detergents and cleaning supplies were observed locked in the laundry room. LPA observed a freezer and a refrigerator in the garage with extra food. Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is no bodies of water on property. There are dual carbon monoxide and smoke detectors that are hard wired and interconnected. Administrator tested detectors at 10:20 a.m. and LPA observed detectors properly functioning. LPA observed sprinklers and a fire door. There are two fire extinguishers both observed fully charged with purchase date 07/12/24. Resident and Staff Files: At 10:50 a.m. LPA reviewed resident and staff files. Files are maintained locked in the staff room. LPA conducted a file review of five (5) out of five (5) resident records to insure compliance of licensing forms. LPA also conducted a file review of three (3) staff records to insure forms and training are up to date and in compliance with licensing forms. Medications: At 12:02 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a cabinet in the kitchen. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Sep 9, 2024

Allegation investigated: Facility admitted a resident with an unstageable pressure injury.

Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit to this facility to conclude the investigation regarding the above allegation. On 01/17/23, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigation Branch. The complaint was accepted by CCL, IB and was assigned to Investigator Lauren Garcia on 01/19/23. LPA met with the administrator Mark Belmont and the purpose of the visit was explained. The complaint alleged the facility admitted a resident with an unstageable pressure injury. LPA conducted an initial complaint visit on 1/18/23 to gather copies of pertinent information from Resident #1 (R1’s) facility file. During the course of the investigation, Investigator Garcia conducted interviews, gathered hospice and wound care documents, and also subpoenaed R1’s medical records. Information obtained from interviews conducted with R1’s Power of Attorney (POA), facility staff, and registered nurse with hospice, revealed that R1 was admitted into the facility on 10/19/22. (Continued to LIC9099-C) Unfounded (Continued from LIC9099) R1 was already receiving hospice services and wound care prior to being admitted to this facility. On 12/27/22 R1 was transported to a hospital and transferred to a skilled nursing facility to receive antibiotics through an IV. A review of R1’s hospice medical records indicate R1 was receiving hospice and wound care service with an agency from 09/16/22 to 12/26/22. R1 was admitted to the hospital on 12/27/22 and then transferred to a skilled nursing facility on 01/03/23. Furthermore, when R1 was discharged from skilled nursing back to this facility on 01/03/23, R1 was also admitted to a new hospice agency with wound care services on the same date, 01/03/23. R1’s hospice and medical records revealed pressure injury was already documented and part of the care plan. Based on the information obtained through interviews with R1’s POA, review of R1’s hospice and medical records this allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted. Copy of report provided. (Continued from LIC9099) On 11/07/2023 LPA interviewed three (3) out of five (5) residents at the facility. One (1) resident was out in the community and another resident refused to be interviewed. Resident interviews revealed they are satisfied with the care they are receiving and facility staff are regularly making rounds to provide assistance. Furthermore, resident interviews revealed they are assisted with hygiene and grooming on a regular basis. Interview with administrator on 01/18/2023 denied the allegation. interview with administrator on 11/07/2023, administrator stated they were still surprised such an allegation was made. Administrator stated they only receive positive feed back from residents' and residents' family members. LPA did not find an individual to corroborate the allegation R1 was unkempt while in care. Therefore, based on LPA's observations and interviews this allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 31-AS-20230117090038

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit for this facility. LPA met with the administrator, Mark Belmont and administrator designee Mylene Veatch and explained the reason for the visit. The facility is licensed for a capacity of 6 with fire clearance for five (5) non-ambulatory residents, and one (1) bedridden. At approximately 10:10 a.m. LPA and administrator tour the physical plant of the facility and the following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. Knives were stored in a locked kitchen drawer. Bedrooms: There are six (6) total bedrooms one of which is for staff use only. Five (5) bedrooms are designated for resident use and are currently private. Bedrooms were observed to be properly furnished with appropriate bedding and sufficient lighting. LPA observed two (2) hallway closets used as storage for extra linens, toiletries, and incontinent care. There are dual carbon monoxide and smoke detectors that are hard wired interconnected. Administrator tested a detector at 10:07 a.m. and LPA observed detectors properly functioning. LPA observed sprinklers and a fire door. There are two fire extinguishers both observed fully charged. One fire extinguisher is located at the kitchen, and the other is in the garage. Bathrooms: There are three (3) bathrooms. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and hand rails. Hot water temperature was measured at 10:14 a.m. and read 118.5 degrees Fahrenheit within regulation. (Continued on LIC809-C) Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to seat up to six residents. The auditory alarms on all exit doors were on and functional at the time of the visit. Fireplace was off and secured with a screen. Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is no swimming pool or bodies of water on property. The laundry room is located in the hallway by the residents' rooms and leads to the attached garage. Laundry room was observed locked. Detergents and cleaning supplies were observed locked in a bathroom cabinet. LPA observed a freezer and a refrigerator in the garage with extra food. Resident and Staff Files: Resident and staff files are maintained locked in the staff room. LPA conducted a file review of resident records to insure compliance of licensing forms. LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms. Medications: Medication and Medication Records are stored in a locked cabinet in the kitchen. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Nov 7, 2023