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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800709
Report Date: 03/09/2022
Date Signed: 03/10/2022 06:03:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20220304121800
FACILITY NAME:MOTHER LOVE RESIDENTIAL CARE HOMEFACILITY NUMBER:
486800709
ADMINISTRATOR:SAN FELIPE, BEBETHFACILITY TYPE:
735
ADDRESS:100 ELENA COURTTELEPHONE:
(707) 645-8057
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 3DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Bebeth San Felipe, LicenseeTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility failed to be clean, safe, sanitary and in good repair at all times
INVESTIGATION FINDINGS:
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On 3/10/2022 LPA Tobola arrived at the facility and met with Licensee, Bebeth San Felipe for the purpose of opening a complaint investigation at Mother Love Residential Care Home. During the investigation LPA toured the facility, made observations, conducted interviews with staff and requested facility documents.

Complaint alleges facility failed to be clean, safe, sanitary in good repair at all times. Based on LPA tour of the facility and observations LPA found multiple locations of the facility to be in unclean and unsanitary condition including facility kitchen, bathroom and backyard.

LPA identified areas of concern that require Licensee to develop plan of action to ensure facility will stay in compliance.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20220304121800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MOTHER LOVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 486800709
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2022
Section Cited
CCR
80087(a)
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Buildings and Grounds 80087(a). The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by:

Based on observations LPA found multiple locations of facility to be in unclean and
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Licensee failed to ensure facility was kept in clean, safe, sanitary and in good repair at all times. Licensee agrees to submit cleaning plan of action to ensure compliance to CCL by POC due date 3/17/2022. Plan must indicate whether Licensee will hire staff or outside agency to clean facility targeted areas. Licensee agrees to submit photo
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unsanitary condition. LPA identified areas listed in LIC9099 which include facility kitchen, bathroom and backyard. This serves as a potential health & safety risk to residents in care.
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proof of corrections for the listed areas of concern. Final POC is to be sent to CCL by POC due date 4/10/2022.
Type B
04/10/2022
Section Cited
CCR
80088)(f)
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Furniture, Fixtures, Equipment, and Supplies 80088(f). Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by: Based on observations and photos
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Licensee failed to ensure facility waste was store and disposed in a manner Licensee agrees to submit cleaning plan of action to ensure compliance to CCL by POC due date 3/17/2022. Plan must indicate whether Licensee will hire staff or outside agency to clean facility targeted areas. Licensee agrees to submit photo
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LPA observed multiple horse flies both alive and dead throughout the kitchen area. LPA also observed fruit flies in the kitchen area surrounding waste items. This serves as a potential health & safety risk to residents in care.
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proof of corrections for the listed areas of concern. Final POC is to be sent to CCL by POC due date 4/10/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220304121800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOTHER LOVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 486800709
VISIT DATE: 03/09/2022
NARRATIVE
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Facility areas of concern in violation of Regulations; Buildings and Grounds 80087(a), Food Service 80076(a)(1) & Furniture, Fixtures, Equipment, and Supplies 80088)(f):

- Mildew and buildup on bathroom surfaces (floor, bathtub toilet)
- Insects (flies and fruit flies) found in kitchen area
- Food and other stored items compiled in kitchen space
- Kitchen refrigerator cleared of any expired foods
- Walls requiring cleaning throughout the facility
- Windows and window sills
- Backyard cleared of recyclable cans and unused items or items in disrepair

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with facility Licensee, whose signature on this document confirms receipt.
A copy of the signed report was emailed to Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20220304121800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MOTHER LOVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 486800709
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2022
Section Cited
CCR
80076(a)(1)
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Food Services 80076(a)(1). All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidence by:

Based on LPA observation and photos
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Licensee failed to ensure food is stored in a safe and healthful manner. Licensee agrees to submit cleaning plan of action to ensure compliance to CCL by POC due date 3/17/2022. Plan must indicate whether Licensee will hire staff or outside agency to clean facility targeted areas. Licensee agrees to submit photo
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LPA found several items within the facility refrigerator that were past expiration date. This serves as a potential health & safety risk to residents in care.
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proof of corrections for the listed areas of concern. Final POC is to be sent to CCL by POC due date 4/10/2022.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5