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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 11/01/2024
Date Signed: 11/01/2024 03:49:42 PM

Document Has Been Signed on 11/01/2024 03:49 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/
DIRECTOR:		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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Maria Riformo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 11/1/2024 at 3:15pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Maria Riformo, Licensee.

While LPA L. Hall was conducting a complaint investigation 15-AS-20230901131403 on 11/1/2024. LPA observed facility did not have a qualified and currently certified administrator. LPA also observed R1 did not have a chest of drawers for clothing in the bedroom.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/01/2024 03:49 PM - It Cannot Be Edited


Created By: Laura Hall On 11/01/2024 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 A
11/02/2024
Section Cited
CCR
87405(a)

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(a) All facilities shall have a qualified and currently certified administrator. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours... When the administrator is not in the facility, there shall be coverage by a designated substitute... This requirement was not met as evidence by:
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Licensee agreed to implement a plan to hire a new administrator and submit plan to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a qualified and certified administrator, which poses a potential health and safety risk to persons in care.
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Type B
11/08/2024
Section Cited
CCR87307(a)(3)(B0

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(a) Living accommodations... shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents... who may reside in the facility. (3) Equipment and supplies necessary for personal care... shall be readily available to each resident. ...the licensee shall assure provision of: (B) Bedroom furniture... a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
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Licensee agreed to purchase a chest of drawers for R1 and submit a photo 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 a chest of drawers for R1, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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