392700814-5-11-2021-27-AS-ABOE-C2WUBD-20210511152609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 05/11/2021
Date Signed: 05/11/2021 03:27:09 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 PARENTS		FACILITY NUMBER:	392700814
ADMINISTRATOR:	VARGAS, BRANDI		FACILITY TYPE:	740
ADDRESS:	488 POELSTRA COURT		TELEPHONE:	(714) 948-0381
CITY:	RIPON	STATE: CA	ZIP CODE:	95366
CAPACITY:	6	CENSUS: 6	DATE:	05/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Denise Ordonez		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Prior to today’s visit Licensing Program Analyst (LPA) Ashley Boothe contacted the Licensee with the following questions: In the last 10 days has anyone who is present in the home facility, includes persons in care, or staff developed any of the follow symptoms associated with a pre-existing condition? No · Fever or chills · Cough · Shortness of breath/difficulty breathing · Fatigue · Muscle or body aches · Headaches · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

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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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: 05/11/2021

NARRATIVE

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Licensing Program Analyst(s) (LPA) Ashley Boothe and Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 5/11/21 at 11:30am. LPAs met with Denise Ordonez, House Manager who contacted Administrator regarding today’s visit. LPA's were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. Administrator, Brandi Vargas indicated she was unable to assist with today's visit and that Denise will sign today's report. Currently this facility has two residents receiving hospice services.

LPA interacted with a random number of residents participating in individual activities during this visit.

The physical plant was toured inside and outside to ensure the safety of the residents.

LPA observed common areas, bedrooms, restrooms, closets, kitchen, laundry room, living room and backyard.

The temperature inside the facility was measured at 75*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.

The hot water was measured at 113*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

LPA observed the centrally stored medications area to be locked and inaccessible to clients.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 12

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: 05/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA's observed chemicals in cabinets in kitchen and bathrooms accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2021
	Plan of Correction
1 2 3 4	The staff removed all chemicals from cabinets accesible to residents during today's visit. POC cleared during today's visit.

Type A

Section Cited

CCR

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA's observed kitchen knife on top shelf of panty unlocked and nails in kitchen drawer to the left of the kitchen sink accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2021
	Plan of Correction
1 2 3 4	The staff locked the pantry door to secure the knife and moved the nails out of the drawer. POC cleared during today's visit.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 12

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: 05/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA's observed a bottle of Melatonin in unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2021
	Plan of Correction
1 2 3 4	The staff removed the bottle of Melatonin from the cabinet and secured it. POC cleared during today's visit.

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in LPA's observed expired milk and biscuits in the refrigerator and only three cans of vegetables in the panty which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2021
	Plan of Correction
1 2 3 4	The staff agrees to remove all expired food and purchase additional food items to maintain supplies of non perishable foods. Staff agrees to send LPA a copy of the receipt for food purchased. Staff discarded expired food during today's visit.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 4 of 12

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: 05/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(9)

Incidental Medical and Dental Care Services

(9) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in LPA's did not observe a first aid kit containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Staff stated she could not find the first aide kit in the facility at this time. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2021
	Plan of Correction
1 2 3 4	During this visit facility received a newly purchased unopened first aid kit. POC cleared during today's visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 5 of 12

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: 05/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in LPA's observed double locked front door, broken kitchen drawers, broken towel bar in restroom, stained carpets, broken dresser drawer, broken light-switch in hallway,and broken microwave. LPA's observed water hose on the ground on back patio and planter posing a trip hazard to residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	The licensee agrees to repair or replace or all items listed above and send LPA pictures of work completed. Staff secured the hose and planter were resolved during today's visit.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA's observed window screens at back bedroom and two sliding doors towards the backyard with holes near the handle which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	The licensee agrees to repair or replace window screens with holes and send LPA pictures of work completed.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 6 of 12

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: 05/11/2021

NARRATIVE

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LPA's did not observe a first aid kit containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Staff stated she could not find the first aide kit in the facility at this time. During this visit facility received a newly purchased unopened first aid kit.

LPA did not observe food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA's observed expired milk and biscuits in the refrigerator and only three cans of vegetables in the panty.

LPA's observed kitchen knife on top shelf of panty unlocked and nails in kitchen drawer to the left of the kitchen sink accessible to residents.

LPA's observed chemicals in cabinets in kitchen and bathrooms accessible to residents.

LPA's observed a bottle of Melatonin in unlocked kitchen cabinet.

LPA's observed double locked front door, broken kitchen drawers, broken towel bar in restroom, stained carpets, broken dresser drawer, broken light-switch in hallway, and broken microwave. LPA's observed water hose on the ground on back patio and planter posing a trip hazard to residents.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 11 of 12

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: 05/11/2021

NARRATIVE

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Upon a file review the following items were discussed to be submitted with any changes annually:
Personnel Report LIC500 with all staff
Qualifications of Administrator
LPA informed Administrator that annual fees in the amount of $495 are due on 5/13/2021. LPA provided PIN code to pay online as an option to licensee.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies observed and cited. Exit interview held, copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC809 (FAS) - (06/04)

Page: 12 of 12