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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 03/01/2022
Date Signed: 03/01/2022 12:07:54 PM


Document Has Been Signed on 03/01/2022 12:07 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: 3DATE:
03/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Denise OrdoniezTIME COMPLETED:
12:07 PM
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On 3-1-22 at 9:55am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a health and safety check visit. LPA was greeted by Administrator Denise Ordoniez and LPA explained the purpose of the visit.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential care facility for the elderly with a current census of 3. LPA was screened upon entry for temperature and asked to sign in with COVID questions. COVID screening questions were asked prior to entry. Facility has 4 bedrooms and 3 bathrooms.

There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and backyard. The facility has a designated infection control lead.

The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. LPA reviewed 5 staffing charts and 3 resident charts.
Water temperature reads 115.6*F in the bathroom and room temperature reads 75*F. LPA observed the facility to have adequate food supply. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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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: 03/01/2022
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Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and purchased on 1/11/22.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Denise Ordoniez.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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