075601208-8-23-2024-15-AS-LHOS-D8BR93-20240820124852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 08/20/2024
Date Signed: 08/23/2024 08:18:09 AM

Document Has Been Signed on 08/23/2024 08:18 AM - 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 HOME		FACILITY NUMBER:	075601208
ADMINISTRATOR:	RIFORMO, HAILEY R.		FACILITY TYPE:	740
ADDRESS:	508 KAYANN COURT		TELEPHONE:	(510) 222-1406
CITY:	EL SOBRANTE	STATE: CA	ZIP CODE:	94803
CAPACITY:	6	CENSUS: 3	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Maria Riformo, Administrator (ADM)		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/20/24 around 08:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Maria Riformo, Administrator (ADM) arrived about 10 minutes later. Co-Licensee currently holds a standard certificate (#6006016740). The facility’s fire clearance was approved for six (6), four (4) may be non-ambulatory residents. Upon entry, LPA observed one (1) resident sleeping and later going to the bathroom. LPA and ADM toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. 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, paper towels and garbage cans. Licensee to increase the surplus of PPE that is centrally stored in the facility and accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 107.8 degrees Fahrenheit (F) and the facility's temperature was 69 degrees (F). Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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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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
	VISIT DATE: 08/20/2024

NARRATIVE

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...continued from LIC809.

Fire extinguisher was observed full and tagged with receipt on 07/05/24. Emergency Disaster Plan is updated. Last safety drill conducted 07/15/24 and is rotational between AM and PM schedules quarterly.

LPA reviewed three (3) staff files with criminal record clearances, and four (4) resident files. After repairs are completed, licensee to remove 3-4 wooden boards, 2 shower glass doors, and a screen in disrepair at the sliding door of the dining room.

The following forms are to be updated and submitted to CCLD 09/03/24:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)
-Infection Control Plan (Reviewed
-Removal of debris

Exit interview conducted and a copy of this report provided to ADM.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2024 08:18 AM - 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: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff files not being completed and updated with training, health screenings and personal rights forms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee to review and update all staff files with CCLD forms and self certify by POC date of 09/03/24.

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by administrator not completing off of the certification requirements as an Administrator which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee to review regulations for all Administrator recertification requirements, apply and pay for the application, and submit proof to CCLD by the POC date of 09/03/24.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2024 08:18 AM - 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: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 3 reviewed staff files not possessing proof of required training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee to review and update all staff files for required training and send a copy to CCLD by the POC date of 09/03/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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