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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 07/02/2025
Date Signed: 07/02/2025 03:16:26 PM

Document Has Been Signed on 07/02/2025 03:16 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: 3DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Maria Riformo, licenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 07/02/25 around 10:25 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 (Licensee) arrived about 10 minutes later who currently holds a standard certificate (#7001621740) exp. 04/06/25. The facility’s fire clearance was approved for six (6), four (4) may be non-ambulatory residents.

Upon entry, LPA observed one (1) resident in the dining area having a telephone conversation. LPA and Licensee 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. The hot water temperature in the shared residents' bathroom measured at 105.3 degrees Fahrenheit (F) and the facility's temperature was 68 degrees F. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/02/2025
NARRATIVE
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...continued from LIC809.

Fire extinguisher was observed full and tagged with receipt and expires 07/05/24. Emergency Disaster Plan is updated. Last safety drill conducted 03/08/25 and is rotational between AM and PM schedules quarterly.

LPA reviewed three (3) staff files with criminal record clearances, and three (3) resident files; all files were incomplete.

-At 11:30 AM: Facility Administrator records have not been updated with CCLD.
-At 11:35 AM: Residents files are not updated with a current Appraisal Needs and Services Plan.
-At 11:35 AM: Personnel files are not updated with Heath Screening, TB testing and Training records.
-At 12:20 PM: PUB 475 regulatory size not posted in the facility.

The following forms are to be updated and submitted to CCLD by 07/23/25:
-Resident Roster (Reviewed)
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-Administrator Certificate(s) (Reviewed)
-Infection Control Plan (Reviewed)
-Liability Insurance (Reviewed)
-Written plan for repairing or removing the patio lattice.

Exit interview conducted and a copy of this report provided to Maria Riformo, Licensee.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/02/2025 03:16 PM - It Cannot Be Edited


Created By: Lisha Holmes On 07/02/2025 at 02:12 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

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 not employing an administrator to carry out their responsibilities of which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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3
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Licensee to provide the required documents to change administrator on record by POC date.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that all personnel records maintained proof of a Health Screening, TB testing, and Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Licensee to provide proof of the required documents and review the regulation by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 03:16 PM - It Cannot Be Edited


Created By: Lisha Holmes On 07/02/2025 at 02:12 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing required training to all staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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2
3
4
Licensee to provide the required documents to change administrator on record by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/02/2025 03:16 PM - It Cannot Be Edited


Created By: Lisha Holmes On 07/02/2025 at 02:13 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not posting the required poster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Licensee to post the required poster by the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/02/2025 03:16 PM - It Cannot Be Edited


Created By: Lisha Holmes On 07/02/2025 at 02:13 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

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 not conducting an annual reappraisal for all residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
1
2
3
4
Licensee to conduct an annual reappraisal for all residents by the POC date.
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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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