Lovely Community Healthcare

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:15 A.M. Upon arrival, LPA was greeted by staff “Suzette” who called the Administrator to inform them of the visit. While waiting for the Administrator, LPA observed six (6) residents in care and one (1) care staff providing supervision and assistance. During today’s visit, Resident one’s (1’s) family members were present and were in the process of moving the resident to a new location. At 10:00 A.M., a second care staff and The Administrator, Cilva Toume arrived at the facility and the reason for the visit was explained. Assistant Administrator, Vana Barberis arrived shortly after. Entrance interview conducted. The LPA and Assistant Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a temperature of 70 degrees Fahrenheit. At 10:46 A.M., hardwire combination of smoke / carbon monoxide detectors were operational at the time of the visit. LPA observed two (2) fire doors. Fire door separating the common area and the resident rooms was functioning properly, however, fire door located on bedridden room (Room#4) had a rubber door stopper preventing the door from closing. The fire extinguisher was observed and fully charged on 04/24/2026. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/03/2026 and they are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Continued fon LIC 809-C Continued from LIC 809-C BEDROOMS: There are six (6) total private bedrooms in the facility designated for residents. All bedrooms are sufficiently furnished and in compliance. Light fixtures and lighting were observed to be sufficient. LPA observed that one resident was using supplemental oxygen; however, "No Smoking – Oxygen in Use" signage was not present in areas where oxygen was in use. Technical Violation (TV) issued. BATHROOMS: There are three (3) bathrooms. Two (2) are private and one is a shared bathroom. Resident restrooms were observed to be equipped with slip-resistant surfaces and grab bars. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all restrooms and ranged within the required range. LPA observed trash cans did not have a tight-fitting lid and they were full. KITCHEN: The LPA inspected the kitchen/food service area at 10:30 A.M. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition; however, kitchen surfaces and stove were unkept. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 117.3 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked in a cabinet under the sink. LPA observed an adequate amount of emergency food and water in a pantry adjacent to the kitchen. CONVERTED GARAGE AND STORAGE ROOM: There are two (2) additional rooms, a converted garage and storage closet space next to room #4. Per Administrator these rooms are being used for staff members to rest. The storage room located next to room #4 room was not locked. At 10:40 A.M. this room contained hand sanitizer, mouth washing and beauty supplies which poses an immediate health, safety risk to persons in care. Additionally, in the converted garage LPA observed cleaning compounds together with extra supplies of canned goods. Technical Violation (TV) issued. A staff member immediately separated chemicals from food supplies. Also, LPA observed two (2) meat products in the refrigerator that did not have a label or information about the items inside. BACKYARD: The entire property is fenced. There is a laundry area /room, with a washer and dryer that remains locked at all times, laundry detergent was observed. The backyard has portable umbrellas for shade with patio furniture including a table and chairs for resident use. All passageways and emergency exits were observed to be clear and free of obstructions and hazards. LPA observed two (2) self-latching gates. Facility has an in-ground pool, which was observed to be fenced with an appropriate lock. Continued from LIC 809-C Continued from LIC 809-C RECORDS: Record review began at approx. 12:28 P.M. Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at approximately 1:30 P.M. The medications are in a locked drawer located in the kitchen. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. During today’s visit LPA informed the Administrator and Assistant Administrator that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Additionally, LPA observed discrepancies with medication count for two residents. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit LPA Conway reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory. The following documents were obtained during today’s visit: Personnel Report (LIC 500), Register of Facility Residents (LIC 9020), and current Liability Insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. An immediate civil penalty of $500 is being assessed on today’s date (07/10/2026) for a violation of the facility’s fire clearance. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Cilva Toume and Vana Barberis Assistant Administrator arrived shortly after and the reason for the visit was explained. Entrance interview. INTERVIEWS: From 10:05 a.m. – 10:29 a.m. two (2) staff and four (4) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:30 p.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/05/2025. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/09/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Report Continued from LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809... BEDROOMS: There are six (6) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms. There are two (2) additional staff rooms / areas (converted garage and laundry/closet space) that have been added / converted without permits, however a LIC200 was submitted on 07/23/2024 to document the change and schedule a fire clearance inspection. The staff rooms / areas are kept locked at all times. RESTROOMS: There are three (3) restrooms. Two (2) are designated as shared / common restrooms and one (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with nonslip surface. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured all resident restrooms and ranged between 113.2- 116.1 degrees Fahrenheit, all within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 11:16 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. There were three (3) meat products in the freezer that did not have a date which poses/posed a potential health, safety or personal rights risk to persons in care. At the time of the visit the date was added. The kitchen faucet was measured for hot water temperature, and it measured 110.8 degrees Fahrenheit at 11:17 a.m. Cleaning supplies and other chemicals are kept in a cabinet under the sink. At 11:18 a.m. the cabinet under the sink was unlocked with multiple cleaning chemicals / solutions which poses/posed an immediate health, safety or personal rights risk to persons in care. At the time of the visit the Administrator locked the cabinet and spoke to staff about the importance of ensuring chemicals are locked and inaccessible to residents in care. LPA observed an adequate amount of emergency food and water in a closet / pantry adjacent to the kitchen. BACKYARD: The entire property is fenced. There is a laundry area /room, with a washer and dryer that remains locked at all times, laundry detergent was observed. The backyard has a portable umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. Facility has an in-ground pool, which was observed to be fenced with an appropriate lock. Emergency exits and passageways were observed free of obstructions and hazards. Report Continued from LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Record review began at approx. 11:36 a.m. Resident Records were reviewed beginning at 11:36 a.m. and Personnel Records at 12:23 p.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Six (6) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at approximately 2:35 p.m. The medications are in a locked drawer located in the kitchen . Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA obtained the following documents - Resident roster LIC 9020, Staff roster -LIC 500, and a copy of the Limited Liability insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Licensee did not provide the correct refund to resident’s representative

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. Upon arrival, LPA met with facility staff who called the Licensee to inform them of the LPA’s visit. LPA spoke with Licensee Cilva Toume at 09:55AM. Licensee arrived at 10:32AM. Entrance interview conducted. The complaint alleges that Resident #1 (R1) had moved into the facility on 12/30/2024 and passed away at the facility on hospice care on 01/05/2025 and R1’s responsible party did not receive a full refund to date. LPA obtained copies of R1’s admission agreement and R1’s documents filled out upon admission. Interview with Licensee revealed that they had discussed refunds and had verbally agreed that no refund would be issued for R1’s fees paid for January 2025 due to additional care R1 required while R1 was present at the facility. LPA reviewed R1’s admission agreement signed by R1’s responsible party and Licensee. R1’s Continued on LIC 9099-C Substantiated admission agreement does not contain language related to refunds issued when a resident is on hospice or fees incurred due to additional care. Admission Agreement does contain language related to $500 non-refundable pre-admission fee, however the line was left blank inadvertently according to Licensee. Title 22 regulation does not contain specific language related to refunds when a resident is on hospice care. Basic services charge for December was $333.33 and Admission Agreement indicates monthly fee is $5000.00 per month. Interview revealed that R1’s personal belongings were removed on 01/06/2025. Licensee confirmed that a check for $333.33 was mailed to R1’s responsible party, however no additional refunds were issued. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 of the CA Code of Regulations and/or CA Health and Safety code, the following deficiencies were cited (refer to LIC 9099-D.) Exit interview was conducted. A copy of today’s report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 29-AS-20250211121654

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Mar 4, 2025

§1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 01/06/2025 and correct refund has yet to be issued, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Licensee agreed to communicate with R1's family related to the refund and whether a pre-admission fee will be included. Remaining refund (excluding amount already refunded) will either be $3666.67 or $3166.67. Proof of refund issued will be provided to CCL by POC due date.

Allegation investigated: Staff is not providing adequate care and supervision to resident. Resident sustained an injury from a fall at the facility.

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to deliver the findings for the allegations listed above. The LPA was greeted by staff and contacted the Administrator via telephone. The Administrator Cilva Toume arrived thereafter, and the LPA explained the reason for the visit. On 07/05/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial 10-day complaint investigation. The LPA met with Staff at 10:35 a.m., Administrator Cilva Toume arrived shortly thereafter, and LPA explained the reason for the visit. During today's visit, the LPA toured the facility, interviewed staff at 9:45 a.m.,10:00 a.m., and 10:15 a.m., interviewed residents at 10:30 a.m. and 10:35 a.m. Attempted interviews with 3rd parties at 11:13 a.m. and 11:29 a.m. and collected pertinent documents. Continues on LIC 9099C... Substantiated Pg.2 Staff is not providing adequate care and supervision to resident. On the allegation that Staff is not providing adequate care and supervision to resident; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and allowed R1 to self-harm by allowing R1 to self injure their fingers. To investigate the allegation LPA Elsie Campos interviewed staff, and administrator on 07/05/2023. The staff’s (S1) interview revealed that R1 came back from the hospital with bite marks to their fingers, however, the bites were covered with bandages. Furthermore, S1 stated that they were attending to R1’s biting injuries by changing the bandages and keeping the wounds clean two times a day, every day. S1 stated that they called the home health nurse on June 20th, 2023, to inform them that they had noticed that R1 had continued to self-bite their fingers. Staff’s (S2) interview revealed that after R1 came back from hospital on 06/18/2023, R1 came back with signs of biting on R1’s hands, “they didn’t look bad, so we covered R1’s palms for prevention, but then R1 started biting their fingers. We informed R1’s responsible party, and the nurse about the concern when R1 came back from the hospital. We (staff) were monitoring R1 throughout the day and night to prevent any further self-harm. The Administrator’s interview revealed that R1 returned from the hospital after the 06/15/2023 fall with home health services. The Administrator added that staff reported right away to the Administrator when they noticed that R1 started biting their hand and fingers; furthermore, the administrator contacted R1’s responsible party and the home health nurse to inform them of the hand/finger biting. On 10/22/2024, LPA Urena spoke with the RP and interviewed them on the phone. The RP stated that when they were changing the dressings on the right hand of R1, they noticed additional self-inflicted injuries to R1’s right hand fingers and hand. LPA Urena was unable to communicate with the attending home health nurse. Home Health was being provided per hospital discharge instructions for the injury to the forehead due to the fall at the facility, and an abrasion to the hand which happened at the hospital. Continues on LIC 9099C... pg.3 Pg. 3 On 10/28/2024, LPA Urena received and reviewed medical records for R1 from the attending hospital. The medical records indicate that R1 was admitted on 06/29/2023 with Diagnosis: open wounds to right hand, necrotic (dead cells/skin tissue) in appearance to the finger. Areas of necrosis in right distal 5th digit. R1 underwent debridement of right hand and right small finger amputation due to gangrene and eschar. Based on the information obtained through interviews and record review, staff was not providing adequate care and supervision to resident; consequently, staff did not notice the change of condition of R1 and allowed R1 to further self-harm an open wound. Therefore, the allegation is deemed Substantiated at this time. Resident sustained an injury from a fall at the facility. On the allegation that Resident sustained an injury from a fall at the facility; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and R1 sustained a fall that required hospitalization. To investigate the allegation LPA Campos interviewed staff, and administrator on 07/05/2023. The interviews revealed that the first time R1 fell on 04/03/2023, it was an unwitnessed fall. Staff was conducting the morning rounds, at approximately 5:30 a.m. at which time, R1 was still in bed. The second time staff did their morning rounds at approximately 6:30 a.m. R1 was found lying on the floor, staff noticed a skin tear, staff applied first aid, contacted the administrator and the administrator contacted the responsible party for R1. R1 was taken to the hospital for evaluation. The second fall happened on 06/15/2023, while staff assisted R1 to use the commode, when R1 got up from the commode, R1 lost their balance, staff were unable to hold them up, and R1 fell to the floor. R1 was taken to the hospital for evaluation. Per the administrator’s interview, R1 came back to the facility with stitches on their forehead. Staff and administrator stated that the R1 walked slowly with the aid of a walker and sometimes needed assistance with transferring. Staff stated that they monitored and assisted R1 throughout the day. Continues on LIC 9099C...Pg. 4 Pg. 4 On 10/22/2024, at approximately 4:00 p.m., LPA Urena interviewed R1’s representative (POA). The POA stated that R1 suffers from dementia and is non-ambulatory. R1 was at risk of falling because R1 was frail, and because R1 still insisted on getting up on their own to use the commode. R1 was admitted to the facility on 01/13/2023. On 04/03/2023, R1 had their first fall, but was not witnessed by staff. Staff found R1 laying on the floor and was observed to have a skin tear on the face, consequently POA was informed of the fall and took R1 to the hospital to be checked out. POA stated that they spoke to the Administrator about getting someone to provide 1-to-1 caregiver for R1, because R1 could get up from the bed on their own if they felt that they needed to use the commode, but needed assistance and was at risking of falling. POA stated that the administrator and the POA worked out a deal for each to pay half of the cost for 1-to-1 caregiver. The 1-to-1 caregiver provided care for about five (5) to six (6) weeks, then the caregiver left. On 06/15/2023, R1 had a second fall, sustained a cut to the face and R1 complained that they could not stand up. R1 was taken to the hospital to be evaluated. Record review of the physician’s report dated 12/06/2022 indicate that R1 had diagnosis of Cognitive Disorder and was non-ambulatory. Page 2)-Under section PHYSICAL HEALTH STATUS for motor impairment: It indicated that R1 had no motor impairments. Page 4) under section CAPACITY FOR SELF-CARE: “Observation recommended for safety”. Review of the R1’s Resident Appraisal (LIC603A) states under SERVICES NEEDED: Needs special observation/night supervision (due to confusion, forgetfulness, wondering) YES. LPA Urena reviewed discharge papers from the hospital dated 06/18/2023. The discharge papers indicated a diagnosis of ‘weakness of bilateral legs, fall, and glabellar laceration (area between the eyebrows and above the nose). Based on the information gathered through interviews and record review, the information revealed that it was agreed between the administrator and the POA that R1 required a 1-to-1 caregiver due to R1’s risk of falling. Furthermore, the Physician’s report stated that “observation was recommended for safety”; and although it does not specify what type of safety, it clearly stated that “observation was recommended for safety”. R1 sustained a fall that required a two (2) day hospitalization. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 29-AS-20230629151129

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(a)(4) · Plan of correction due date: Nov 8, 2024

Care of Persons with Dementia (a)This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia… (4) There is an adequate number of direct care staff to support each resident’s. physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision, which caused R1 to sustain falls and injuries.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: POC: Administrator agreed to do the following: Review the regulation and obtain training for all staff (Administrator and staff) on care of persons with dementia.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(3)(b) · Plan of correction due date: Nov 8, 2024

Reappraisals-(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental... Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health... (b)The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision allowing R1 to cause an injury that required amputation.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: POC: Administrator agreed to do the following: Review regulation and obtain training for all staff (Administrator and staff) on residents’ change of conditions and reporting requirements.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility for a required annual inspection. Upon arrival, the LPA was greeted at the door by staff. Administrator Cilva Toume was contacted by staff and arrived shortly thereafter. At approximately 2:30 p.m, the LPA and staff/Ms. Toume began the physical plant tour (inside and outside) to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The LPA observed common area to be clean and properly furnished at the time of the visit. The LPA observed the fire extinguisher to be fully charged and last purchased on 05/23/2024. Smoke and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level of 74 degrees F. Cleaning supplies and disinfectants are stored inaccessible under the kitchen sink cabinet, in the locked garage and laundry room which is only accessible from the outside area. KITCHEN: Kitchen/dining area observed. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. Supply of perishable food items good for two days and non-perishable food items for seven days observed at the facility during todays visit. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 6 (six) resident bedrooms. Staff bedrooms have been add (converted garage and laundry/closet space) observed and were occupied by staff. Administrator will provide updated facility sketch. RESTROOMS: Observed restrooms to be clean and sanitary and in operating condition with grab bars and non-skid surfaces during todays visit. Hot water measured at 118 degrees Fahrenheit in resident restrooms. RECORDS: Residents’ records review began at 5p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Due to time constraints, the LPA’s will return at a later date to complete the inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview conducted. Copy of the report provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.