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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 01/25/2021
Date Signed: 01/25/2021 03:30:31 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:
01/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nataley MartinezTIME COMPLETED:
03:30 PM
NARRATIVE
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On January 25, 2021, Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit via telephone call with Licensee Nataley Martinez. Census 5. LIC 500 and LIC 808 requested.

On 12/22/2020 LPA attempted a Facetime case management visit with Licensee at approximately 3:30pm. Licensee stated she was not at the facility and was at Starbucks around the corner, she would be at the facility in three minutes. LPA called her back and Licensee kept delaying the Facetime. At 4:23 LPA and Licensee connected to a Facetime call. LPA stated the purpose of a virtual health and safety check but with limited time LPA would reschedule the visit.

On 12/23/2020 LPA conducted an in person unannounced case management health and safety visit. LPA provided technical assistance and cited deficiencies pursuant to COVID universal precautions not met. Upon LPA's arrival staff made attempts to contact Licensee and Administrator but they were both unable to come for COVID precautionary measures. Staff stated Licensee was symptomatic and in line to get a test and administrator was on quarantine for 14 days for known exposure.

On 12/27/2020 at 9:38pm LPA received an email from Licensee stating "Wednesday I was in line to get my Covid19 Test (I have no symptoms) but was unable to take the test. I'm currently out of town now for the new year but can be reached by phone or email". There was not mention of two suspected staff members positive.

On 1/3/2021 at 10:10pm LPA received an email from Licensee stating "Denise started feeling sick on Dec. 24, but didn't think anything of it, and my other caregiver Ruth started feeling sick also on Dec 27, both stayed home to see if it was just a flu, but decided to get a Covid test and both came out positive. We also had to send out a resident because she was feeling sick, I will fax over a incident report. I have everyone quarantined, I'm gonna try to see how I can get them all tested. I'm out of town and heading home tomorrow first thing in the morning".

On 1/4/2021 LPA contacted Licensee for initial COVID call at 3:44pm, she was unable to provide information to LPA as she was driving. LPA requested a time to call back and agreed upon 6:45 to 7pm. LPA contacted and left a voicemail for Licensee at 6:56pm and 7:26pm. Licensee did not attempt to call or email LPA on 1/4/2021.

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
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 3
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: 01/25/2021
NARRATIVE
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On 1/5/2021 LPA contacted Licensee at 11:08am for initial COVID call and provided technical assistance to report to Local Health Department and other items showing as not started or in progress for COVID preparedness and requested incident reports be sent to LPA via fax and email.

On 1/7/2021 LPA attempted COVID positive daily follow up call at 2:39pm, Licensee's voicemail box was full, LPA emailed at 2:45pm, and called again 4:22pm voicemail box full. LPA contacted the facility and staff contacted Licensee to call LPA around 5pm. LPA provided technical assistance to move visitations screening outside, requesting PPE return demonstrations, and reviewing PIN 20-38-ASC.

On 1/8/2021 at 3pm via Facetime LPA, Licensing Program Manager (LPM) Liza King and California Department of Public Health Nurse Consultant toured the facility. Items Licensee stated as completed on COVID intake form were observed to not be in practice in the facility. Observed isolation rooms of person's under interest doors open with no signage posted about isolation status, Licensee enter isolation room in full PPE but not dispose of it, hand hygiene not observed during the visit, furniture placed less than 6 feet apart, no paper towels or touchless covered trash receptacles observed in the facility. Discrepancy in documentation of when resident isolation started, during COVID intake Licensee stated 1/3/2021, during TA visit Licensee stated isolation started on 12/24/2020. Licensee's father picked up PPE from the Sacrament South Regional Office (RO).

Daily calls from RO on 1/9/2021, 1/10/2021, 1/11/2021, 1/12/2021, and 1/13/2021.

On 1/19/2021 LPA emailed Licensee to follow up on Licensee's email requesting plan of corrections extension until the house was cleared. LPA inquired about COVID positive status and Licensee reported two new positive residents. LPA called Licensee at 3:28pm and left a voicemail, no response from Licensee to LPA.

Daily Calls from RO on 1/20/2021 and 1/21/2021.

Licensee reported that a LIC624 was submitted to the RO via fax for two of four residents positive and zero of two staff positive. No fax transmittal receipts have been submitted to LPA by Licensee per LPA's request to show proof of fax confirmation for documents not received.

Licensee stated staff one showing symptoms of COVID continued to work from 12/24/2020 to 12/27/2020 during infectious period. Staff two showing symptoms of COVID continued to work on 12/27/2020 during infectious period.



Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Nataley. 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: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 01/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/26/2021
Section Cited

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Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.

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This requirement is not met as evidence by:

During interview and observation the Licensee did not comply with COVID precautionary measures by allowing symptomatic staff to work during their infectious period and not following COVID isolation procedures. This poses an immediate health and safety risk to residents in care.
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Request Denied
Type A
02/16/2021
Section Cited

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Reporting Requirements: Occurrences, such as epidemic outbreaks...or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement is not met as evidenced by:

Licensee did not submit incident reports of positive staff and residents to licensing in a timely manner. This poses an immediate health and safety 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: 01/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3