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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 03/18/2022
Date Signed: 03/18/2022 04:37:11 PM


Document Has Been Signed on 03/18/2022 04:37 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:
03/18/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Denise OrdoniezTIME COMPLETED:
04:45 PM
NARRATIVE
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On 3-18-22 at 12:53pm, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen arrived at this facility unannounced to conduct a quarterly visit. LPA was greeted by Administrator Denise Ordoniez and LPA explained the purpose of the visit.
LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living room 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 6. LPAs were 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. "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. Facility menu is 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 6 resident charts.
Water temperature reads 118.5*F in the bathroom and room temperature reads 75*F.

{Cont. on 809C}

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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: 03/18/2022
NARRATIVE
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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 7 days of non-perishables and 2 days of perishable items on hand. Fire extinguisher is fully charged and purchased on 1/11/22. During facility tour, LPAs observed cleaning fluid, bug spray, and various cans of paint accessible to residents in care. Additionally, LPAs observed unlocked medication accessible to residents in care. LPAs requested the following documentation: Resident roster, staffing roster, updated plan of operation including dementia plan, lease agreement, emergency contact information for residents.

Per California Code of Regulations, Title 22, Division 6 deficiencies were observed during this visit. An immediate civil penalty of $250 is accessed due to repeat violation. Exit interview was held with Denise Ordoniez and a report was given to Denise.. Appeal rights provided.

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

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/18/2022 04:37 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: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2022
Section Cited

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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:
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Based on observation, cleaning fluid, bug spray, and multiple paints cans were unlocked in garage and accessible to residents in care. This poses an immediate health and safety risk to resident in care. An immediate civil penalty of $250 is accessed due to repeat violation.
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Licensee will read regulation 87309 and submit a signed declaration of understanding to LPA by POC due date.
Type A
03/21/2022
Section Cited

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Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored. (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by: Based on observation, medication were stored in a buffet cabinet, unlocked and accessible to residents in care. This 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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