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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 07/08/2022
Date Signed: 07/08/2022 12:13:47 PM


Document Has Been Signed on 07/08/2022 12:13 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:MARTHA ARREGUINFACILITY TYPE:
740
ADDRESS:488 POELSTRA COURTTELEPHONE:
(714) 948-0381
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: DATE:
07/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Martha ArreguinTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to discuss records requested by the regional office that were not received. LPA Jensen met with Licensee Nataley Martinez and discussed the purpose of today's visit.

On 5/18/22 Community Care Licensing Division issued a written request for records in relation to Trust and Solvency Audits with a submission due date of 6/14/22. The Licensee requested an extension which the Regional Office granted through 7/5/22. The requested documentation has not been received to date.

Administrator Martha Arreguin advised she is unable to to provide the requested financial records during today's visit

As a result of today's visit deficiencies are being cited from the California Code of Regulations, Title 22, and civil penalties are being assessed. An immediate civil penalty of $250 is being assessed. An exit interview was conducted and a copy of this report was handed to the Administrator and Appeal Rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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 07/08/2022 12:13 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: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2022
Section Cited

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The licensee...shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. This requirement was not met as evidenced by:
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Based on a written financial records request that was issued on 5/18/22 with a submission due date of 7/5/22, the Licensee did not provide the requested documentation.
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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: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/08/2022 12:13 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: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2022
Section Cited

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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....
Ability to maintain or supervise the maintenance of financial and other records.
This requirement was not met as evidenced by:
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Based on the LPA's request on 7/8/22 for financial records that the Administrator was unable to comply with.
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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: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3