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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:40:46 PM


Document Has Been Signed on 06/09/2022 01:40 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
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: 6DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nataley MartinezTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at the facility to open a complaint investigation. During the course of the visit LPA Jensen conducted a case management visit based on information that was obtained related to staff 1. LPA Jensen explained the purpose of the visit to Licensee Nataley Martinez.

LPA Maja Jensen reviewed a time sheet for S1 showing 36 hours worked from June 2, 22 to June 4, 2022. LPA Maja Jensen also interviewed the Licensee and staff member 2. LPA Maja Jensen requested the staff file for S1 and was advised by licensee Nataley Martinez that she is unable to produce the staff file.

The following deficiencies were cited from the California Code of Regulations, Title 22. See 809 and LIC421BG. An immediate civil penalty was assessed in the amount of $300. Civil penalties will be assessed daily until the deficiency is corrected.

An exit interview conducted with licensee Nataley Martinez and a copy of report and appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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


Document Has Been Signed on 06/09/2022 01:40 PM - 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, 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited

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(g) 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 or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement was not met as evidenced by:
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Based on interviews conducted with a staff member and the Licensee and a record review of S1's time sheet, the licensee employed a staff member who's responsibility included care of residents without complying with Title 22, CCR 87411(g)(1-3). This 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/09/2022 01:40 PM - 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, 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement was not met as evidenced by:
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Based on LPA Maja Jensen's request for a staff file for S1 that the licensee was unable to comply with. This poses a potential 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3