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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601208
Report Date: 11/01/2024
Date Signed: 11/01/2024 03:17:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230728084348
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: 4DATE:
11/01/2024
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Maria Riformo, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident is not provided with clean bed linen

Staff do not assist resident with grooming
INVESTIGATION FINDINGS:
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On 11/1/2024 at 2:05pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Maria Riformo, Licensee and explained the reason for the visit.

The Department interviewed the reporting party (RP), staff, obtained and reviewed records.

Allegation: Resident is not provided with clean bed linen.

During interview with RP it was sated that R1’s bed did not have a blanket and the fitted sheet was stained. During interview with S1 it was stated linens are changed

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20230728084348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099.

once a week or as often as needed. Based on observation, besides the sheets that were on the beds, the facility owned five (5) fitted sheets, several flat sheets, and two (2) of the fitted sheets was for a bed size that wasn’t present at the facility. LPA observed one (1) sheet that was stained and had to be discarded.

Allegation: Staff do not assist resident with grooming

R1 was admitted into the facility 2/13/2013. Review of the admission agreement indicated that at the time of admission R1 was able to self-groom. RP stated during interview that R1’s hair was not washed and R1 was wearing a dirty shirt. On the functional capability assessment and the appraisal needs and services plan dated 8/2/2023 it indicated R1 was not capable of self-grooming. S1 stated that a caregiver would groom R1. LPA reviewed pictures that were submitted and observed R1’s nails were long and had dirt underneath. The pictures also displayed R1’s hair unkempt.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20230728084348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 075601208
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
87307(a)(3)(C)
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(a) Living accommodations... should be related to the facility's function... (3) ...supplies necessary for personal care and maintenance of adequate hygiene... the licensee shall assure provision of: (C) Clean linen... top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels... The quantity shall be sufficient to permit changing at least once per week... The linen shall be in good repair.
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Licensee agreed to purchase linen and submit photos and receipts to CCLD by POC date.
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This requirement was not met as evidence by:
Based on observation the Licensee did not comply with the section cited above in having sufficient quantity of linen, which poses a potential health and safety risk for persons in care.
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Type B
11/15/2024
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports
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Licensee agreed to keep a log or notes of bathing and grooming schedule and submit a 2-week copy to CCLD.
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Based on interviews and observation the Licensee did not comply with the section cited above in assisting resident with personal grooming, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230728084348

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: 4DATE:
11/01/2024
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Maria Riformo, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff do not meet residents' dietary needs
Staff do not assist resident with bathing
Staff do not allow resident to keep and use their own personal possessions
Facility is not maintained clean and sanitary at all times
INVESTIGATION FINDINGS:
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On 11/1/2024 at 2:05pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Licensee, Maria Riformo, and explained the reason for the visit.

The Department interviewed the reporting party (RP), staff, obtained and reviewed records.

Allegation: Staff handled resident in a rough manner

During interview with RP it was stated that R1 had bruises on forearms and forehead that were sustained by staff handling R1 in a rough manner. Record review of Contra

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20230728084348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099.

Costa Regional Medical Center dated 7/31/2023 indicates bruising but not from abuse or neglect.

Allegation: Staff do not meet residents' dietary needs.

During initial interview with RP it was stated that R1 had lost a significant amount of weight between 2020-2023. S1 stated a weight loss log is not kept unless it is noticeable. Review of the physician’s report dated 09/27/2019 did not have R1’s weight listed but did state that R1 was a 2000 ADA calorie diet.

Allegation: Staff do not assist resident with bathing

Based on initial interview with RP it was stated R1 was wearing a dirty shirt, hair was not washed, and she was unkempt. S1 stated that R1 was given a bath every other day and more if needed.

Allegation: Facility is not maintained clean and sanitary at all times

On 6/16/2023, the RP visited the facility and stated during interview the floors were “dirty”. Pictures with unknown dates were also submitted showing the floor underneath a bed was unsanitary. LPA L. Holmes toured the facility during visit on 8/02/2023 and observed the facility to be sanitary.

Allegation: Staff do not allow resident to keep and use their own personal possessions

During record review it indicated that on the functional capability assessment and the appraisal needs and services plan dated 8/2/2023 that R1 is not capable of self-grooming. RP stated a brush was requested for R1 and staff brought a

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20230728084348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099C.

“community brush” and someone removed R1’s hygiene products from her room. S1 stated during interview that R1’s brush is kept in the bathroom, however, when LPA L. Holmes toured facility she observed the brush sitting on R1’s night stand along with personal hygiene products in R1’s room.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.














SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6