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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 09/22/2021
Date Signed: 09/23/2021 11:30:57 AM

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: 4DATE:
09/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nataley MartinezTIME COMPLETED:
12:55 PM
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On 9/22/2021 at 9:30am, Licensing Program Analyst (LPA) Ashley Boothe, arrived unannounced to conduct a Health and Safety Visit. Prior to today's visit LPA contacted Licensee for COVID screening and left voicemail. LPA conduct COVID screening upon arrival with facility Administrator Denise Ordonez who stated no staff or clients have experienced symptoms of COVID within the last 10 days and explained the purpose of today’s inspection. Current Census is 4 of which 1 is Hospice. Administrator accompanied LPA on facility tour during today's visit and Licensee arrived shortly after LPA's arrival.

LPA reviewed resident records. As of today 3 residents are on site with Resident one (R1) admitted to short term stay at skilled nursing facility after a fall, incident report not received by the Regional Office (RO) was observed with post it "waiting for confirmation". LPA observed Resident two (R2) on Hospice services with plan in place for a prohibited health condition, Hospice notification not submitted or retained on site. LPA observed Resident three (R3) passed, Death Report received by the RO in July 2021, Hospice notification not submitted or retained on site. LPA observed Resident four (R4) passed, Death Report not received by the RO in September 2021, post it "waiting for confirmation" and Hospice notification not submitted or retained on site. LPA observed Resident five (R5), not on Hospice Services with full bed rail on bed. LPA observed resident records with no update care plans noting observations of in conditions for residents and all documents not stored easily accessible to staff with all requirements as listed in Title 22, Section 87506 Resident Records.

LPA interacted with a random number of clients during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, garage, restrooms, bedrooms, and common living areas to not be clean in good repair In that carpets in Room 4 are soiled and stained, variety of items stored in garage and side yard not in use and not disposed of, exterior electrical outlet missing cover, hose coiled on the ground on patio, and broken grab bars in two of two showers. LPA observed toxins, knives, centrally store medications stored inaccessible to clients.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 4
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: 09/22/2021
NARRATIVE
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Continued from 809.

The temperature inside the facility was measured at 78*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 108*F within regulatory range of is not less than 105*F and not more than 120*F.

The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution.

LPA observed fire extinguisher last purchased on 1/5/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed 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 observed COVID precautionary measures and signs for universal precautions are posted in common areas and restrooms stocked with paper towels, hand soap, touchless covered trash cans and posted hand washing signs. 30 day supply of PPE stored off site.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited

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Postural Supports (a) ...Postural supports may be used under the following conditions. (5) Under no circumstances shall ... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care. This requirement is not met as evidence by:
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Based on observation, interview and records review the licensee did not comply with the section cited above in that R5, not on Hospice service does have full bedrails on bed in room 4 which 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: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require..
This requirement is not met as evidence by:
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Based on observation, interview and records review the licensee did not comply with the section cited above in that Incident reports, hospice notifications and death reports for R1- R5 were not all submitted or confirmed to be submitted to the department which poses a potential health and safety risk to residents in care.
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Type B
10/22/2021
Section Cited

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Maintenance and Operation
(a) 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.
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Based on observation and interview the licensee did not comply with the section cited above in that carpets in Room 4 are soiled and stained, variety of items stored in garage and side yard not in use and not disposed of, exterior electrical outlet missing cover, hose coiled on the ground on patio, and broken grab bars in two of two showers which 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: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4