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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:02:25 PM

Document Has Been Signed on 09/02/2021 01:02 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Minerva San Felipe, LicenseeTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Minerva San Felipe (MSF).The facility currently provides care for 3 clients all of which were present at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be in minor disrepair but Licensee is/ working with a maintenance staff to repair the kitchen and backyard. Facility was at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA observed a jar of fermented banana peels used for fertilizer in the kitchen that attracted fruit flies. The jar was immediately removed. LPA observed several food items past expiration date which were immediately removed. Fire Extinguisher was found to be last charged on 7/15/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations.

Toxins are stored in a locked cabinet in the facility laundry room. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. All client bedrooms have lighting & appropriate furnishings. LPA observed mildew buildup on bathroom sink and toilet. Facility bathroom also has a strong smell of urine and buildup on floor. Licensee agrees to conduct a deep cleaning of facility and maintain a cleaning schedule.

Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. All clients and staff are vaccinated with no symptoms. No surveillance testing is conducted as over 70% of staff and clients are vaccinated. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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