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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:52:37 PM

Document Has Been Signed on 06/07/2022 02:52 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Licensee, Minerva San FelipeTIME COMPLETED:
03:00 PM
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On 6/7/2022 LPA Tobola conducted a Case Management visit for the purpose of following up on concerns found during facility complaint investigation and was greeted by Licensee, Minerva San Felipe. During complaint investigation conducted on 6/7/2022 LPA Tobola found that resident R1 and Licensee had a verbal agreement in which R1 requested for Licensee to cash out a stimulus check that R1 received and hold as a fund reserve for personal item requests or emergency purposes. LPA spoke with both Licensee and resident R1 confirming the agreement. The items that R1 would request were purchased by Licensee and deducted from the reserve fund total amount.

LPA reviewed records, interviewed Licensee and resident R1 and discussed a updated plan on handling R1's stimulus fund amounts to prevent potential risks of commingling. LPA issued Technical Advisory and discussed plan of action with Licensee.

No deficiencies cited during the visit.
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.

LIC809 (FAS) - (06/04)
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