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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:34:22 PM


Document Has Been Signed on 04/12/2024 04:34 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: 4DATE:
04/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria Riformo, LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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On 4/12/2024 at 2:45pm, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct a Case Management visit. Licensee, Maria Riformo, arrived at 2:55pm

When LPAs arrived to facility to conduct a complaint investigation (15-AS-20230728084348) on 4/12/2024, LPAs observed two (2) people at the facility. LPAs was informed by the two (2) people that they were visitors and no staff was present.

*An immediate civil penalty of $500.00 will be assessed on today's date for absence of supervision*

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report, LIC421M, and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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Document Has Been Signed on 04/12/2024 04:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2024
Section Cited
CCR
87411(a)

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 (a) Facility personnel shall at all times be sufficient in numbers... to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines... This requirement was not met as evidence by:
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Licensee arrived at 2:55pm, 10 minutes after LPAs arrived. Deficiency cleared during visit.
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Based on observation and interview the Licensee did not comply with the section cited above in having staff present at the facility, 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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