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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800709
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:21:23 PM

Unsubstantiated


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:
06/07/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Minerva San Felipe, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility failed to meet residents needs
Facility failed to safeguard residents personal property
INVESTIGATION FINDINGS:
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On 6/7/2022 Licensing Program Analyst (LPA) Tobola conducted a Complaint Investigation Visit to deliver complaint findings and was greeted by Licensee, Minerva San Felipe. During the course of the investigation LPA toured the facility, reviewed resident records made observations and conducted interviews with staff and outside parties.

Complaint alleges facility failed to meet resident (R1) needs regarding lack of sufficient food and resident not allowed to smoke. Based on LPA observations, review of records and interviews with staff, outside parties and resident R1, LPA found that R1 was given a written doctor's orders not to smoke after receiving a surgical operation. In addition, based on interview with R1 LPA was informed that all residents receive three meals a day. R1 stated that when they do get hungry throughout the day they have access to a large bin of snacks available at all times.

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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 2
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: 06/07/2022
NARRATIVE
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Complaint alleges facility failed to safeguard resident (R1) personal property regarding the allocation and spending of R1's stimulus check. Upon LPA interviews with staff, outside parties and resident R1, LPA found that R1 is able to handle their own cash resources based on R1's Physician's Report. Based on interviews with R1 and Licensee, LPA was informed that a verbal agreement was made between R1 and the Licensee in which a stimulus check received by R1 was to be cashed by the Licensee as a reserve fund. Both parties agreed the fund was for R1's use on personal requested items or emergency purposes in which the Licensee recorded each purchase deducting from the total amount. LPA conducted a review of item list records and price amounts along with receipts and confirmed several items purchased by R1's statements to match records.

A finding that the complaint allegations, facility failed to meet residents needs and facility failed to safeguard residents personal property are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2