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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800709
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:04:30 PM

Document Has Been Signed on 04/15/2022 03:04 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:
04/15/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Minerva San Felipe, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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On 4/15/2022 LPA Tobola arrived at the facility unannounced and was greeted by Licensee, Minvera San Felipe (MSF). The purpose of the visit is to follow up on the Plan of Corrections for facility violations under the following regulations:

- Buildings and Grounds 80087(a)
- Furniture, Fixtures, Equipment, and Supplies 80088(f)
- Food Services 80076(a)(1)

LPA observed the kitchen and found it to be free of insects. Compost items have all been removed from the kitchen sink and no other signs of items that could serve as a breeding ground for additional insects. Storage boxes found in the kitchen and overflow of contents have been relocated to a spare bedroom.

LPA observed the facility refrigerator and found multiple food items that are past the expiration date and produce items that appear to be spoiled which have not been removed. Licensee agrees to thoroughly clean the kitchen of all food contents that are spoiled or past the expiration date. (Photos taken)

LPA observed facility bathroom and found it to be in an unsanitary condition. Mildew and buildup was observed along the bathtub, floor and toilet. (Photos taken)

LPA observed facility backyard and found multiple bags of aluminum cans that Licensee agreed to recycle or remove still located throughout the backyard. (Photos taken)

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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: 04/15/2022
NARRATIVE
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Licensee provided CCL with a Facility Cleaning Plan to be conducted and completed by POC due date 4/10/2022, which has not been followed or completed. LPA is requesting for a new plan of action to ensure facility is in compliance.

***Civil Penalties assessed in the amount of $1000.00 for failure to correct violations of regulations 80076(a)(1) Food Services & 80087(a) Buildings & Grounds, within the agreed original Plan of Correction due date of 4/10/2022 of the original violation dated 3/9/2022.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal Rights given. Signatures on file.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2022 03:04 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/15/2022 at 01:32 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: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
80076(a)(1)

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Food Services 80076(a)(1). All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidence by:
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Licensee failed to ensure food items available to clients are safe and of the quality necessary to meed client needs. Licensee agrees submit an updated cleaning plan to CCL in detail of how Licensee will ensure food items are monitored and kept in safe quality by POC date 4/20/2022.
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LPA found several items within the facility refrigerator that were past expiration date or spoiled. This serves as a potential health & safety risk to clients in care.
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Licensee to fully clean kitchen and kitchen refrigerator of any expired or spoiled food items. Photo proof is to be submitted to CCL by POC date 4/20/2022.
Type B
04/29/2022
Section Cited
CCR80087(a)

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Buildings and Grounds 80087(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 was not met as evidence by:

Based on observations LPA found multiple locations of facility to be in unclean
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Licensee failed to ensure facility is kept in a safe, clean and sanitary condition for clients in care. Licensee agrees to submit updated cleaning plan to CCL in detail of how Licensee will ensure facility will remain in safe, sanitary and good condition by POC date 4/20/2022.
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unsanitary condition. LPA identified areas which include facility bathroom and backyard. This serves as a potential health & safety risk to residents in care.
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Licensee to deep clean bathroom and remove all cans and disposable items from the backyard and provide photo evidence to CCL by POC date 4/29/2022.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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