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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 01/04/2021
Date Signed: 01/27/2021 12:14:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A LOVING PLACE FOR YOUR PARENTSFACILITY NUMBER:
392700814
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:488 POELSTRA COURTTELEPHONE:
(714) 948-0381
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: 5DATE:
01/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff one (S1) TIME COMPLETED:
11:30 AM
NARRATIVE
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On December 23, 2020 Licensing Program Analyst LPA Ashley Boothe conducted an unannounced health and safety case management visit at 9:30am with Staff one (S1). Licensee and administrator were not able to come to the facility per COVID precautionary guidelines. The facility is a one story four bedroom and three bathroom house. Current census of 5 residents of which 1 hospice.

LPA rang the doorbell and was allowed entry to the facility by S1 who screened LPA for temperature and recorded temperature in a log kept in the kitchen. LPA stated the purpose of the visit and requested S1 to contact Licensee and Administrator, S1 contacted both, neither was able to be present for the visit. LPA observed no signs posted on the entrance to the facility following department guidelines for COVID precautions. S1 was not wearing a mask when she opened and allowed entry to LPA. She put it on prior to taking LPA's temperature. Staff are practicing self screening of temperatures and recorded. LPA observed a handwritten sign on the wall to the left of the entry door instructing staff to wear a mask at all times while in the facility. LPA provided technical assistance to S1 to post COVID precautions and visitor policy on the outside of the front door, to designated a screening and sanitizing area at the front door so visitors do not come into the facility prior to being screened, and to document additional screening questions, provided via email to Licensee.

LPA observed three residents finishing up breakfast and drinking coffee. Resident one R1 requested another cup of coffee and it was observed S1 put milk in R1's coffee and added more per R1's request and eating buttered potato. During records review it was noted that on the resident's appraisal she is lactose intolerant and states no dairy. The LIC 602 did not note a dairy allergy. LPA provided technical assistance to review all resident's LIC 602 and complete reappraisals if discrepancies are noted or provide notation of residents preferences. Perishable and non perishable food observed in the kitchen was in ample supply, properly stored, and R1, Resident two (R2), and Resident three (R3) all stated they were happy with the food provided. Fruit was available to residents on the kitchen island.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814
VISIT DATE: 01/04/2021
NARRATIVE
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LPA observed physical plant was clean but not in good repair. The cabinets to the left and right underneath the kitchen sink were observed to be unlocked and chemicals stored in them. The fire extinguisher in the kitchen tag had been removed and there was not a receipt of when it was purchased or last inspection. LPA observed knives/sharps area to be locked. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, thermometers, antiseptic solution and guide, but was missing tweezers. LPA provided technical assistance to replace tweezers. LPA observed the locked laundry room where extra EPA registered cleaning supplies were available. LPA observed 4 resident rooms lighting was in working order. In master bedroom, LPA observed a tv resting on top of the dresser in the master bedroom that was too big for the dresser so that the feet hung off the side of a chest unsecured, R2 stated they have the wall mount for the tv and no one has been by to put it up since it was purchased and brought to the facility, time unknown, and a tall bookshelf positioned to the right of a resident's bed that was unsecured and wobbly, a tension rod with a curtain to partition the open concept master bath that was loose, and in the master shower the door seal was broken and hanging off the glass enclosure and there was no skid matt or safety grab bars, R2 stated he has requested for since arriving for safety bars in the shower. In Resident four (R4)'s bedroom a glass closet sliding door was off the track leaning up against the other closet door unsecured. In R1's bathroom there was a cracked soap holder in the shower and a broken towel bar in the tub. LPA observed restrooms in the facility to have hand washing signs posted and soap but did not have any paper towels and LPA observed cloth towels in two of three of the restrooms.

LPA reviewed resident records and observed confidential information to be kept in binders on an open shelf in the living room. LPA observed resident temperature checks to be missing entries for R1 on 12/5/2020 and R4 on 12/6/2020. LPA observed centrally stored and Mars for Resident five (R5) and records were recorded and medication matched. Both records were not organized in a way easily accessible to staff, LPA provided technical assistance to reorganize the binders.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Nataley. A a copy of this report was provided to Nataley via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Nataley is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/06/2021
Section Cited

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80087(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement is not met as evidenced by: LPA and S1 observed the facility is not maintained and in good repair which poses an immediate risk to residents in care.
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Type A
01/06/2021
Section Cited

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87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met as evidenced by: S1 did not protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that S1 did not wear a face covering while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/06/2021
Section Cited

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87309 (a)(1) Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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This requirement is not met as evidenced by: LPA and S1 observed chemicals unlocked and improperly stored in the cabinets in the kitchen which poses an immediate risk to residents in care.

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Request Denied
Type A
01/06/2021
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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This requirement is not met as evidenced by: LPA and S1 observed a fire extinguisher without purchase receipt or inspection record which poses an immediate risk to residents 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2021
Section Cited

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87506 (c) Resident Records All information and records obtained from or regarding residents
shall be confidential.
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This requirement is not met as evidenced by: The facility did not secure resident records. S1 and LPA observed resident records were stored on a shelf in the living room. This poses a potential risk to residents 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5