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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881308
Report Date: 09/09/2025
Date Signed: 09/09/2025 12:29:38 PM

Document Has Been Signed on 09/09/2025 12:29 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A PLACE OF LOVEFACILITY NUMBER:
331881308
ADMINISTRATOR/
DIRECTOR:		MOJICA, FLORENCEFACILITY TYPE:
735
ADDRESS:1360 N PALM AVETELEPHONE:
(951) 665-3192
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 0DATE:
09/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Florence Mojica, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 09/09/25 Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit. LPA met with administrator Florence Mojica and observed the following during today's visit:

-LPA observed for the facility to have two (2) live in caregivers. Caregiver #1 (C1) was observed to have fingerprint clearance but was not associated. Caregiver #2 (C2) was observed to not have criminal record clearance. Deficiency cited and civil penalties are being assessed. Please note that C2 began moving out during LPAs visit.

- LPA observed for there to be medication belonging to an unknown individual during today's visit. LPA was informed during an interview conducted with C2 pertaining to complaint control number 18-AS-20250903160204, that the medication belonged to an individual that was deceased. However through additional investigation LPA, was informed that there was a medication that was filled for the same individual on 09/08/25. It was then revealed by C2, that the individual was not deceased, but had required a higher level of care and was dropped off at the hospital in San Bernardino about three (3) months ago. A citation is being issued for false claims.

Further per a file review conducted the governing body was observed to not be in good standing as the FTB is suspended as of May 2025. deficiency cited. Please note that LPA verified and received a copy of the the facility's valid liability insurance.

An exit interview was conducted where a copy of this report, 809D, and appeal rights were reviewed and provided to administrator Florence Mojica.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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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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Document Has Been Signed on 09/09/2025 12:29 PM - It Cannot Be Edited


Created By: Javina George On 09/09/2025 at 11:20 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A PLACE OF LOVE
FACILITY NUMBER: 331881308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2025
Section Cited
CCR
80065(i)(1)

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(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement is not met as evidenced by: C2 not having
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Administrator agreed to have C2 move out of the facility. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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obtained criminal record clearance, and residing in the facility. This posed an immediate health, safety and personal rights risk to persons in care.
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Type A
09/10/2025
Section Cited
CCR80065(i)(2)

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(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019. This requirement is not met as evidenced by: C1 is not
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The licensee agrees to associate C1 to the facility using the Guardian system. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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associated to the facility and they are residing at the facility. This poses an immediate health, safety and personal rights 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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Javina George
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 12:29 PM - It Cannot Be Edited


Created By: Javina George On 09/09/2025 at 11:45 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A PLACE OF LOVE
FACILITY NUMBER: 331881308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2025
Section Cited
CCR
80012(a)

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(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as misleading info was given. This poses a potential health,
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The licensee agrees to conduct an inservice with the staff/live in caregivers on interacting with department staff. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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safety and personal rights risk to persons in care.
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Type B
09/23/2025
Section Cited
CCR80063(a)(1)

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(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order
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The Licensee agrees to get the governing body in good standing proof of POC is to be submitted to the department by 5pm on the due date indicated.
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to ensure such accountability. This requirement is not met as evidenced by: the FTB has been suspended since May 2025. This poses a potential health, safety and personal rights 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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Javina George
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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