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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 06/02/2022
Date Signed: 06/09/2022 11:19:26 AM


Document Has Been Signed on 06/09/2022 11:19 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:A LOVING PLACE FOR YOUR PARENTSFACILITY NUMBER:
392700814
ADMINISTRATOR:DENISE ORDONEZFACILITY TYPE:
740
ADDRESS:488 POELSTRA COURTTELEPHONE:
(714) 948-0381
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: DATE:
06/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nataley MartinezTIME COMPLETED:
12:00 PM
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This report is a result of an amendment. The original report was attached to the wrong facility and is being recreated to correct the error.

On 6/2/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit related to potential personal rights matter reported by the Licensee. LPA Jensen met with Licensee Nataley Martinez and explained the purpose of today's visit.

LPA Jensen requested copies of the file for resident 1 (R1) and resident 2 (R2) and a copy of the staff file for staff 1 (S1). In addition LPA Jensen requested a copy of the staff roster with contact phone numbers, a staff schedule for the month of May and a resident roster for the month of May.

Licensee Nataley Martinez provided copies of the file for S1, staff schedule, staff roster and resident roster during the course of the visit. Licensee Nataley Martinez advised the copies of files for R1 and R2 will be emailed to community care licensing at maja.jensen@dss.ca.gov later this same day of 6/2/22 as there was no access to a scanner at the facility on this date.

A records review will be conducted at a later time and follow up visits for this case management will be conducted.

As a result of today's visit no deficiencies were cited per the California Code of Regulations Title 22, Division 6.

An exit interview was conducted a copy of this report given to Licensee Nataley Martinez.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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