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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:04:40 PM


Document Has Been Signed on 07/14/2022 03:04 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HM LOVE & CARE HOMEFACILITY NUMBER:
075601208
ADMINISTRATOR:RIFORMO, HAILEY R.FACILITY TYPE:
740
ADDRESS:508 KAYANN COURTTELEPHONE:
(510) 222-1406
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 3DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Matthew Riformo, AdministratorTIME COMPLETED:
03:10 PM
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On 07/14/2022 at 2:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA met with staff, Romeo Planas and explained the purpose of the visit. Licensee Maria Riformo and Administrator Matthew Riformo (ADM) arrived about 10 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, face shields, gowns, gloves, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. ADM to post 20 seconds to hand washing signs in the kitchen and bathroom, remove towels after each use, purchase a 30 day supply of PPE, and create an isolation cart for infection control. 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; ADM to provide a covered garbage can for the bathroom. There is a surplus of PPE centrally stored inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 108.4 degrees Fahrenheit (F) and the facility's temperature was 70 degrees (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be kept updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided to Matthew Riformo, Administrator.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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