Rn3 Loving Care Home IV

Type of visit: Required - 1 Year

On 11/18/2025 at 12:20 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Enjei Lee and explained the purpose of the visit. At 1:30 pm, Meina Wu, the administrator arrived and met with the LPAs. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 04/22/2024. Emergency Disaster Plan was last posted on 11/18/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/03/2025. LPA reviewed 4 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications. The following documents were reviewed during the visit: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099*** THE FOLLOWING DEFICIENCY WAS OBSERVED: · At 1:10 PM, LPA's observed that the fire extinguisher was expired with a date of 04/22/2024. The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2025

Type of visit: Required - 1 Year

On 10/28/2024 at 12:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 1-year Annual Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose for the visit. LPA was greeted shortly after by Meina Wu, Administrator (ADM) LPA requested a staff and resident roster. LPA was screened at the entry. Masks, gowns, gloves, additional sanitizer, and a visitor sign-in log is centrally stored inside the facility that is accessible to all care staff. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage and backyard. LPA observed adequate lighting and good repair of all rooms. All shared areas had covered garbage cans. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and paper towels. Hot water temperature was measured at 110.1 degree Fahrenheit (F) and the facility's temperature was 69 degree (F). Fire extinguisher was observed full and last inspected on 04/22/2024. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. Emergency disaster drill last conducted 07/2024. The following forms are to be updated and submitted to CCLD by 11/04/2024: -LIC500 Personnel Report & Resident Roster -LIC308 Designation of Administrative Responsibility -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Co-Administrator Certificate Continued on LIC809C... ...continued from LIC809C. -At around 03:45 PM Mattresses in the hallway, wooden boards, black metal fencing, paint, and debris from construction on the side of the house and in the backyard. Deficiencies observed (see LIC809D) and cited from the California Code of Regulations. Exit interview conducted and a copy of this report provided to Meina Wu, Administratorthe state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Resident sustained a fracture due to insufficient care by staff

On 09/09/2024 at 12:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Meina Wu of the reason for the visit. The Department's investigation included, but was not limited to, interviews with staff, residents, and the Reporting Party (RP). The Department obtained and reviewed records pertaining to resident R1, which included facility records, medical records, home health records, hospice records, and death certificate. Continued on LIC 9099-C . . . Substantiated Continued from LIC 9099-A The complaint alleges that resident R1 sustained a fracture while in care. R1 was a 90-year-old female with reduced bone strength due to osteoporosis putting her at a significantly higher risk of sustaining a fracture after a fall. Interviews of the administrator and staff revealed that R1 fell sometime in early February of 2022 (specific date unknown due to lack of documentation nor report of the incident to the Department). After R1’s fall, staff did not secure immediate medical care for R1. On 2/21/2022, after R1 complained of being in “extreme pain”, the family transported R1 to the Kaiser Permanente Hospital. Kaiser Permanente medical records from 02/21/2022 show that R1 had sustained a new compression fracture of the T12 vertebrae. When interviewed, neither the administrator nor most staff members considered R1 to have a risk of falling during the 4 years she lived at the facility. The 03/17/2020 Physician’s Report did state that R1 had a risk of falling, as did the 02/21/2022 Physician’s Report after her fall. Medical records, home health records, and Kaiser Permanente Hospice records all state that R1 was at risk of falling. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D. A $500 immediate civil penalty is assessed today; Licensee was informed that additional civil penalties are still being determined based on Health & Safety Code 1569.49(f). Exit interview conducted and a copy of this report was provided. Continued from LIC 9099-A The complaint alleges that Resident R1 sustained a stage 4 pressure injury due to lack of care by staff. R1 developed a pressure injury on her left heel and began receiving wound care from home health. The wound eventually went away but began again within a few weeks. R1 began home health again but had two pressure injuries, one on her heel and the other on the coccyx. The wound on the coccyx got worse and R1 was placed on Hospice. The wound on R1’s coccyx continued to get worse, eventually going all the way down to the bone. R1 was receiving home health care when the stage three pressure injury on her coccyx occurred. The pressure injury continued to get worse leading to R1 being placed back on hospice care. Oakland Kaiser Hospice Site Director N1 stated that she had no concerns with the care R1 was receiving while she was at the facility. N1 also stated that the facility staff were following instructions by rotating R1 as much as they could and were doing everything, they could for R1. N1 explained that it is normal for these wounds to happen and get worse quickly when someone whose health was declining as quickly as R1’s was. Facility staff advised investigator that they saw the “red mark” on R1’s coccyx and that they notified the home health nurse of the mark. Facility staff was changing R1’s dressing on her wound every time they needed to and believed they were doing everything they could. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2024 · control 15-AS-20230831144512

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Sep 10, 2024

1569.269 Enumerated rights . . . (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . . This requirement is not met as evidenced by: 1 of the 4 facility staff identified R1’s risk of falling. Physician’s Reports before and after her fall in early February 2022 stated that R1 was at risk of falling. Due to her age and condition, facility staff were negligent by not immediately getting emergency medical care for R1 after her fall.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: A formal conference with CCLD will be scheduled at a later time. A $500.00 immediate civil penalty is assessed on this day. Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f)

Type of visit: Case Management - Deficiencies

On 09/09/2024 at 12:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Meina Wu of the reason for the visit. During the investigation of complaint 15-AS-20230831144512, it was discovered by the Department that neither the administrator nor the staff had documented Resident R1’s fall in early February 2022. Additionally, neither administrator nor staff had submitted the required unusual incident report (LIC 624) to the Department concerning R1's fall when she sustained a new compression fracture of the T12 vertebrae. 2 Type-A deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 10, 2024

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes . . . when such observation reveals ... a physical health condition ... the licensee shall ensure that such changes are documented ... This requirement is not met as evidenced by: Record reviews of complaint 15-AS-20230831144512 uncovered that staff had not documented R1's fall in early February 2022, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: A formal conference with CCLD will be scheduled at a later time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(1)(B) · Plan of correction due date: Sep 10, 2024

87211 Reporting Requirements (a) Each licensee shall furnish ... the Department ...(1) A written report ... within seven days of ... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Record reviews of complaint 15-AS-20230831144512 uncovered that staff had not reported to the Department the injury sustained from R1's fall in early February 2022, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: A formal conference with CCLD will be scheduled at a later time.

Type of visit: Required - 1 Year

On 12/1/2023 at 9:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Maria Martinez and explained the purpose of the visit. Administrator, Meina Wu, arrived at 9:55am. The Administrator currently holds a certificate (#6022847740) that expires on 12/12/2024. The facility’s fire clearance was approved for eight (8) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) total bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/26/2023. Emergency Disaster Plan was last posted on 03/30/2022. First aid kit was observed to be complete. Fire drill was last conducted on 10/1/2023. Continued on LIC809. Continued from LIC809. LPA reviewed five (5) staff records and all were complete. LPA reviewed seven (7) residents files and all were current and complete. LPA requested the following documents to be submitted to CCLD by 12/8/2023. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 610E Emergency Disaster Plan Liability Insurance Resident roster No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 1, 2023