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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426708
Report Date: 01/31/2023
Date Signed: 01/31/2023 10:24:31 AM


Document Has Been Signed on 01/31/2023 10:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ABOUNDING LOVE HOME CAREFACILITY NUMBER:
336426708
ADMINISTRATOR:DELA CRUZ, DENNISFACILITY TYPE:
740
ADDRESS:13213 NAPA VALLEY COURTTELEPHONE:
(951) 961-1303
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
01/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Cheryl De La Cruz, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility regarding complaint #18-AS-20220927205726. The LPA met with Staff, Orlando Trajico, and informed him of the purpose of the visit.

During the investigation, an interview revealed staff lock the refrigerator door due to a resident taking items out of the refrigerator and not eating what was removed. The LPA did see latches for a lock on the refrigerator on January 23, 2023, during a visit. Per Administrator, Cheryl De La Cruz, the staff are no longer locking the refrigerator. This posed a potential threat to the health, safety, and personal rights of the residents in care. A citation will be issued.

An exit interview was conducted with De La Cruz over the phone; this report was reviewed, and a copy was provided, along with appeal rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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 01/31/2023 10:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ABOUNDING LOVE HOME CARE
FACILITY NUMBER: 336426708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as
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Per Administrator, the latches will be removed and a photograph will be submitted as proof.
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eating, sleeping, or elimination. This requirement was not met, as evidenced by: Based on interview & observation, the Licensee did not ensure residents had access to food. Interview revealed staff utilized a lock on the refrigerator door due to a resident taking items out & not eating what was removed.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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