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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:03:13 PM

Document Has Been Signed on 11/01/2024 02:03 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/
DIRECTOR:		SAN FELIPE, BEBETHFACILITY TYPE:
735
ADDRESS:100 ELENA COURTTELEPHONE:
(707) 645-8057
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Minerva San Felipe (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA), Cuadra arrived unannounced at the facility for the purpose of conducting a required 1 year inspection and met Licensee, Minerva San Felipe. Annual fees are current.

LPA/Licensee toured the facility and observed the facility to be at a comfortable temperature with all exits free from obstruction. However, during the tour, LPA/Licensee observed the kitchen was clean, but there were insects around the fruit, so LPA/Licensee had a discussion about it. Licensee agreed to re-organize and/or store some items in a different way to keep insects away from the fruit. Fire Extinguisher was found to be last charged on October 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in clients bathroom measured at 107.1 F degrees, within regulation of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. 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. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Clients bedrooms were furnished per regulation. The facility does not handle cash resources. Medications were centrally stored and locked.

LPA initiated file review at 12:00pm. Three client and two staff files were reviewed. All clients have care plans and medical assessments on file. All staff have required CPR/1st aid and required training hours were updated. Administrator certificate for administrator Minerva San Felipe 6017058735 expires 04/18/2025. Medication and medication records were reviewed.

Licensee provided the following documents to LPA: LIC308 Designation of facility responsibility and LIC 500 Personnel report. 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 given to the Licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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Document Has Been Signed on 11/01/2024 02:03 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/01/2024 at 01:10 PM
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: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA/Licensee observed the kitchen was clean, but there were insects around the fruit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee agrees to ensure there are measures taken to ensure the facility is free of insects and flies. Licensee to submit the facility plan to control insects/flies in the home. Plan to be submitted to CCL by POC date of 11/08/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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