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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:50:46 PM

Document Has Been Signed on 10/21/2022 03:50 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: DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:TIME COMPLETED:
04:00 PM
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On 10/21/2022, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Minerva San Felipe. The facility currently provides care for 3 clients all of which were present the time of visit.

LPA arrived at the facility and had temperature checked. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was located at the front door and to be last charged on 7/28/2022 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. Additional storage room located in facility hallway contained additional non perishable food and snacks for clients. LPA conducted a sample file review for 3 of 3 staff and found all to have current CPR and 1st Aid certification on file.

Toxins are stored in facility laundry room and maintenance closets all found to be secured. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides all hygiene product to clients when requested. All client bedrooms have lighting & appropriate furnishings. Extra linens were stored in storage closet and available to clients. Medications and facility records are kept stored in the kitchen kept inaccessible to clients. Facility has snacks readily available in client common area and is replenished multiples times throughout the day. LPA measured water at faucets accessible to clients which measured at 116.2 degrees F which is within Title 22 regulations between 105 and 120 degrees F.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2022
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Clients are currently under isolation ensuring social distancing and awaiting return to their day programs. Clients were observed to be engaging in various personal activities provided by day programs. During the inspection LPA observed floor tiles located in both client bedrooms and client common area to have slight cracking. Licensee has attempted to repair the tiles but found to be loosening. LPA issued Technical Violation and Licensee agrees to repair or re-secure the loose tiles. Photo evidence to be submitted to CCLD by 10/28/2022.

Infection Control:
Facility is to submit updated Infection Control Plan to CCLD for review by 10/28/2022. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature based on change of condition.

LPA will follow up with Technical Violation. No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 11/4/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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