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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 10/16/2023
Date Signed: 10/16/2023 11:49:09 AM

Document Has Been Signed on 10/16/2023 11:49 AM - 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:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Minerva San FelipeTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Mother Love Residential Care Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee, Minerva San Felipe, and was granted access into the facility.

LPA and Licensee toured the facility. LPA observed the facility to be at a comfortable temperature with all exits free from obstruction. However, during the tour, LPA observed the kitchen being uncleaned (See LIC 809D). LPA observed fruit flies during the inspection (See LIC 809D). Fire Extinguisher was found to be last charged on October 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in clients bathroom measured at 116 degrees, within acceptable range of 105 to 120 degrees F. However, the sink in the clients bathroom was clogged (See LIC 809D). There was sufficient perishable and non-perishable foods located in the kitchen. Medications were centrally stored and locked. Medication files were reviewed. Cleaning products and other toxins are located in the laundry room. There was a supply of Linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. During the Required 1 year inspection, staff files were reviewed. LPA observed that all three staff members who provide care and supervision to clients in care do not have the training hours as outlined in Title 22 regulations (See LIC 809D). Resident files were reviewed. LPA learned that 3 of 3 client files do not have Needs and Services Plan that has been updated yearly (See LIC 9102-Technical Violation).

(Report continued on LIC 808C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/16/2023
NARRATIVE
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In addition, LPA observed that the LIC 602 for 2 of 3 clients were available for viewing. One client did not have the LIC 602. Licensee disclosed that the LIC 602 is still at the doctors office (See LIC 9102-Technical Violation). Infection Control Plan and Emergency Disaster Plan will be discussed at a later date and time. Client and staff interviews will also be conducted at a later date and time.

Deficiencies are 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 was conducted, and a copy of this report was signed and given to the Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2023 11:49 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/16/2023 at 11:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited due to the facility not being cleaned and sanitary which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Plan of Correction shall include cleaning the facility and ensuring that the kitchen is also cleaned as outlined in Title 22 regulations. Furthemore, LPA requested the facility to submit a plan of future compliance and also document on an LIC 9098 the understanding of this regulation.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the kitchen, the licensee did not comply with the section cited above due to the facility kitchen not being sanitary and fruit flies were observed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Plan of Correction shall include cleaning the kitchen and ridding the facility from fruit flies. Furthemore, LPA requested the facility to submit a plan of future compliance and also document on an LIC 9098 the understanding of this regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/16/2023 11:49 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/16/2023 at 11:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the client bathroom, the licensee did not comply with the section cited above in 1 out of 1 client bathroom sinks had a clog which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Plan of Correction shall include unclogging the sink and ensuring that there is no clogs. Furthemore, LPA requested the facility to submit a plan of future compliance and also document on an LIC 9098 the understanding of this regulation.
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of staff records, the licensee did not comply with the section cited above in 3 out of 3 staff members did not provide proof of training nor was it retained in the staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2023
Plan of Correction
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Plan of Correciton shall include training ALL staff and properly documenting it for Licensing. Furthemore, LPA requested the facility to submit a plan of future compliance and also document on an LIC 9098 the understanding of this regulation. Licensee requested an extension to get staff members trained. Extension granted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
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