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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800709
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:19:28 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
07/20/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20220720144306
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:
07/27/2022
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Minerva San Felipe, LicenseeTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility not in compliance with fire clearance
Facility is not clean, safe, and sanitary
Food is inaccessible to clients in care
INVESTIGATION FINDINGS:
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On 7/27/2022 LPA Tobola arrived at the facility and met with Licensee, Minerva 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 reviewed resident documents.

Complaint alleges facility is not in compliance with fire clearance. Upon tour of the facility and observations, LPA found fire extinguisher to be expired and last charged on 7/15/2021. In addition, LPA inspected facility smoke detectors and found smoke detector in client's (C1) bedroom to be inoperable. LPA also observed facility hallway to be missing smoke detector from designated location.

Complaint alleges facility is not clean, safe, and sanitary. Upon tour of the facility and observations, LPA found facility flooring in clients' (C1, C2, C3) bedrooms to have cracked/loose tiling which serves as a tripping hazard to clients in care.

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

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 4
Control Number 21-AS-20220720144306
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: 07/27/2022
NARRATIVE
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LPA also found the client restroom to have a strong smell of urine and confirmed with Licensee of the smell. In addition, LPA observed cobwebs along the ceilings of the restroom and several rooms throughout the facility.

Complaint alleges food is inaccessible to clients in care. Based on tour of the facility, interviews with staff, file review and observations, LPA found that the Licensee secures snacks and other food items in the kitchen. License explained that each client has snacks available in bins located in their bedrooms for use in between meals which LPA observed in clients' (C2 and C3) bedrooms. However, LPA found that client C1 did not have a snack bin in their bedroom and no dietary or eating behavior restrictions stated in C1's Physician's Report indicating that food items are to be locked.

The allegations, facility not in compliance with fire clearance, facility is not clean, safe, and sanitary and food is inaccessible to clients in care are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20220720144306
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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited
CCR
80076(a)(4)
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80076(a)(4) Food Services - (a) In facilities providing meals to clients, the following shall apply:(4) ...snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.
**This requirement was not met as evidenced by:
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Licensee is to develop a plan to ensure all clients have access to healthy snacks in between meals. Licensee agrees to contact clients' (C1, C2 & C3) medical providers to identify any dietary restrictions that could determine a waiver request for locked food storage. Plan is to be submitted to CCLD by POC due date 8/8/2022.
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Based on observation and interview, Licensee did not ensure the regulation above due to food storage room and kitchen containing dry food, canned goods and snacks a for clients to be locked. This is a potential personal rights risk to clients in care.
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In addition, Licensee to review regulation 80076 and submit a LIC9098 Proof of Corrections form to CCLD indicating that they will remain in compliance by POC due date 8/8/2022.
Type B
08/08/2022
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 and Licensee found and confirmed restroom to have a strong smell of urine.
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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 written plan of action addressing areas of concern to CCL by POC due date 8/8/2022. Photos proof of corrections including removal of spider webs and repair of flooring are to be submitted to CCLD by 8/10/2022.
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In addition, LPA observed multiple spider webs along ceilings of restroom and several other rooms throughout the facility. LPA also found tiling in clients' (C1,C2, C3) bedrooms to be broken/loose serving as a tripping hazard. This is a potential personal rights and health & safety risk to clients 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220720144306
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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
80020(a)
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80020(a) Fire Clearance - All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. ** This requirement has not been met as evidenced by:
Based on observations LPA found smoke
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Licensee to check all smoke alarms and immediately replace any missing or inoperable alarms. Licensee to also take fire extinguisher for inspection/recharge. Lastly, Licensee to submit LIC9008 Proof of Correction to CCL by POC date 7/28/2022 in order to clear the deficiency.
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alarm in hallway removed and an additional smoke alarm in client C1's bedroom to be inoperable. LPA also found fire extinguisher to be past inspection date of 7/15/2022. This poses as an immediate health & safety risk to clients 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4