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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:44:42 PM


Document Has Been Signed on 04/29/2022 04:44 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:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Martha ArreguinTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/29/22 Licensing Program Analyst (LPA) Maja Jensen and Licensing Program Manager Liza King arrived at the facility unannounced to conduct a required one year annual visit. LPA Jensen and LPM King met with Administrator Martha Arreguin and explained the purpose of today's visit.

The facility is a single story building with one central entry point. LPA and LPM were screened at the entrance and signed in. LPA Jensen toured the facility including but not limited to the living room, dining room, kitchen, garage, laundry room, 4 bedrooms, 2 bathrooms and backyard. Lighting was adequate throughout and night lights were installed in hallways. The temperature was set at 75 degrees which is within the required range of 68-85 degrees and all rooms were clean and sanitary.

The medications, knives and toxins were observed to be stored in locked cabinets. The facility was observed to have in excess of a 7 day supply of non-perishable food and a 2 day supply of perishable food. The fire extinguisher was purchased on 1/11/22 and is in compliance. The fire alarm and carbon monoxide was tested while at the facility and observed to be working.

LPM King reviewed 6 resident files and 6 staff files. All resident files contained incomplete documents. The resident file for resident 1 (R1) contained a LIC 603A that was not dated. The resident file for resident 2 (R2) contained an LIC 625 that was not signed. The resident file for resident 3 (R3) contained an LIC 603 that was incomplete. The resident file for resident 4 (R4) contained an LIC 603 and an LIC 625 that was not dated. The resident file for resident 5 (R5) contained an LIC 625 that was not signed or date. The resident file for resident 6 (R6) contained an LIC 625 that was not signed or dated.
The following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. Failure to correct the deficiencies may result in civil penalties.
An exit interview was conducted with the Administrator. A copy of this report were provided to the Administrator and Appeal Rights.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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Document Has Been Signed on 04/29/2022 04:44 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: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 appraisals were not completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee agrees to complete and verify that all appraisals and needs and service plans are signed and dated
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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