Loving Hearts Care Home 111

Type of visit: Required - 1 Year

On 04/03/2026 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff, Joy Awa. Licensee, Rose Marie Devera arrived during visit at approximately 10:00AM. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. The facility currently approved for capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 residents in care and 2 staff members on-site. Facility is a 1 story building with 5 Resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. 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. At approximately 11:05AM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked housekeeping closet in the laundry room and under the kitchen sink. Water temperature measured 110.6 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 07/02/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet closet next to the dining room. LPA advised the facility keeping the facility signal system always on (Technical advice given). Continued on LIC809-C page... Continued from LIC809 page... At approximately 11:45AM, LPA reviewed 4 resident records and found 4 of 4 residents have current care plans, signed admission agreements, and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. At approximately 12 PM, LPA reviewed 4 staff records. 4 of 4 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were present. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Rose Marie Devera #7033992740 expires 11/01/2026. LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 02/02/2026. The licensee provided all requested annual documents for filing. No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 3, 2026

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.

Type of visit: Required - 1 Year

On 05/22/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff, Joy Awa and Julietta De Jesus. Licensee, Rose Marie Devera arrived during visit at approximately 10:00AM. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. The facility currently approved for capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 4 residents in care and 2 staff members on-site. Facility is a 1 story building with 4 Resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. 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. At approximately 10:35AM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. During the tour LPA observed two gardening beds in the backyard needs repair on the sidewalk. Licensee agrees to repair them as soon as possible in a week. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature measured 110.6 degrees F and 113.4 degree F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected and charged on 06/07/2024. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the dining room. Continued on LIC809-C… Continued from LIC809… At approximately 11:45AM, LPA reviewed 4 resident records and found 4 of 4 residents have current care plans, signed admission agreements, and physician's orders on file. However 1 out of 4 residents did not have current physician's report on file. Last physician's report for R1 dated to 05/01/2024 which is over a year since last medical assessment have done. Licensee stated that they have done medical assessment for R1 previously however the licensee wasn’t able to find in file (Technical Violation given). Licensee agrees to submit updated medical assessment to the CCL before 06/02/2025. Medication records are thorough and contained physician's orders for each resident. At approximately 12:25PM, LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were present. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Rose Marie Devera #7033992740 expires 11/01/2026. LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 04/04/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 06/05/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 22, 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.

Allegation investigated: Resident's needs are not being met. Insufficient staffing.

On 11/06/2024, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Licensee, Rose Marie Devera. Reporting Party (RP) alleges that Resident 1's (R1’s) needs are not being met and that the facility has insufficient staffing which RP says have resulted in facility staff declining R1’s requests for assistance with transferring to their wheelchair to be taken outside or to shower. LPA conducted 10-day complaint investigation visit on 08/28/2024 and obtained documents, made observations, and conducted interviews with Staff (S1), Staff 2 (S2), Licensee, R1 Resident 2 (R2), and Resident 3 (R3). Based on LPAs interviews, LPA received conflicting information regarding the above allegations. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... On 8/28/2024 LPA received copies of R1’s pre-placement appraisal, IPP, and care plan documentation from Licensee which confirm that R1 has a known, documented history of refusing transfer assistance to go outside or to shower as well as physically and verbally abusive behavior towards care staff. Additionally, on 8/28/2024, LPA received a copy of the facility’s LIC500 Staff Roster & work schedule showing that the facility typically has 2 staff working during the day shifts and 1-2 staff working the evening shift, depending on residents' care needs. The facility is licensed for a maximum of 6 residents. Based on record review, interviews conducted, and observations made, the allegations of resident's needs are not being met and insufficient staffing are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 21-AS-20240826170955

Type of visit: Case Management - Incident

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... 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.the state’s words, verbatim · CDSS document, May 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 24, 2024

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 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.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: 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 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.

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, May 13, 2024

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Post-Licensing Inspection. There are currently 6 residents at the facility. There were 2 staff on duty at the time of inspection. Caregiver Dinah Belandres arrived at 9:45AM and Administrator Rose Devera arrived at 10:00AM. The facility was clean and well-organized, and a comfortable temperature. All signage was up and in a highly visible location. One resident was resting in the living room, supervised. The other resident were resting in there bedrooms with a family member visiting in bedroom #3. The kitchen was well stocked with perishable and non-perishable food items, as specified in Title 22. Opened containers will need to be labeled and dated. The facility was a comfortable temperature. Residents were clean and dressed appropriately. The fire extinguisher was accessible and fully charged last serviced on 06/13/2023. Carbon monoxide (1) and smoke detectors (8) alarms were tested and operational. Medications were locked and inaccessible to residents and unauthorized persons. Bathrooms were clean and equipped with hand grips and non-slip mats. Inspection of 2 out of 2 resident files showed that Admissions Agreements and Physician's Reports were up to date. 2 out of 2 staff files showed that staff are up to date on training and have first aid and CPR. Deficiencies observed during inspection: LPA observed unlocked chemicals under kitchen sink with lose lock LPA observed unlocked sharps (scissors and knife) LPA observed unlocked laundry detergent and fabric softener LPA observed a wheelbarrow with tools (saw/hedge cutter/pliers) LPA observed water temperature 134.7 and 132.4 in residents bathrooms LPA observed staff not fingerprinted and not assigned to the facility Continue on LIC809C Continue from LIC809 Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Administrator and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 26, 2023

87309(a) STORAGE SPACE - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: unlocked chemicals accessible to residents. In addition, LPA found a knife and a pair of scissors located in an unlocked kitchen drawer. Unlocked cleaning supplies in bathroom, laundry room and under kitchen sink. Wheelbarrow with tools in backyard all accessible to residents in care. This poses as an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator failed to ensure chemicals and sharps were kept secured and inaccessible to residents in care. Administrator agrees to read and understand the regulation and create a safety checklist for staff to complete and signage posted in the facility to ensure future compliance. Copy of safety checklist and photos of signage submitted to CCL by POC due date 10/26/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(e)(2) · Plan of correction due date: Oct 25, 2023

(e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 2 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA observed that hot water temperatures were 134.7.degrees F and 132.4 degrees F.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature is within regulation by POC date of 10/25/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 10/31/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 26, 2023

87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering...all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. This requirement is not met as evidenced by: Based on LPA record review the faciltiy failed to ensure S1 have a finger print clearance before working in the faciltiy which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator agrees to submit plan to ensure all individual are finger print cleared before working in the facility, submit to CCL by POC 10/26/2023. Administrator agrees to ensure S1 finger prints are cleared before returning to work in facility. ***Civil Penalty in the amount of $100 was assessed due to facility failing to obtain finger print clearance for S1.