502700876-2-11-2021-27-AS-ABOE-BY67MS-20210211204738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700876
Report Date: 02/11/2021
Date Signed: 02/11/2021 09:04:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	A LOVING PLACE		FACILITY NUMBER:	502700876
ADMINISTRATOR:	VARGAS, BRANDI		FACILITY TYPE:	740
ADDRESS:	2800 CATALA WAY		TELEPHONE:	(714) 948-0381
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 5	DATE:	02/11/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Nataley Martinez and Ryta Martinez		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA’s) Eric Stone, (LPA) Ashley Boothe, conducted an unannounced Prelicensing visit in person on 2/11/2021 with Licensee Ryta Martinez and licensee applicant Nataley Martinez and designee Staff one (S1). LPA's arrived at facility at 9:45am licensees were called and both arrived by 10:45am. Upon LPA's arrival a male resident was being transported to a different facility by staff member S1, she instructed another staff member to provide transport while we waited for licensee. As of today, current census is 5 residents. The facility is a three bedroom, two bath house with a living room, dining room, kitchen, and second living room, and laundry room. Resident's have access to all areas except the garage. Two of three staff observed with criminal record clearance and associated in the Licensing Information System. Observed visitor policy and visitor logs and COVID signs posted on the front door. Staff and visitors enter the facility through ringing the locked front door, sanitizing supplies were available near front door, thermometer, sign in sheets were observed and Staff two (S2) asked questions of LPA's per COVID precautions. PPE masks and hand sanitizer were available in the front entrance. COVID signs posted in dining room, front room, kitchen and bathroom and main living space. Observed physical plant was unclean and in need of repair. Licensee, S1 and LPA's observed carpet had visible stains and dirt, walls marked, chipped paint and cracks, kitchen and master bathroom cabinets broken and showed signs of water damage, gutters cracked with moss, grass growing and water dripping from gutter at the front entrance even though it was dry weather conditions, light bulbs out in master bathroom and kitchen, backyard fence boards fallen down, fence gate stuck when opening, nails sticking out of fence and pointing towards resident accessible areas, two water faucets in master bathroom not producing water pressure, oven door loose, one window screen in backyard had torn off two sides, screen door had hole and was sticking in the track, lighting cover in kitchen overhead lighting missing. Continued of 809 C. Page 1 of 3.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE	FACILITY NUMBER: 502700876
	VISIT DATE: 02/11/2021

NARRATIVE

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Continued from 809. Page 2 of 3

Staff had returned from shopping during the visit, observed kitchen was stocked with canned and dried goods, frozen food, meat, and perishables. Soap, sanitizer, paper towels, and hand washing signs were available at kitchen. Communal Dining Meals were served in dining room with 2 chairs on table, other options included eating in rooms and main living spaces TV trays used. Kitchen trash can observed without a lid.

Observed three recliners in living room not spaced 6 feet apart per COVID precautions. All residents live in shared 2 person bedrooms. Residents observed eating breakfast and lunch during visit. Residents observed watching tv or in bed during visit. Administrator stated if weather permits residents can go outside.

Measured water temperature read at 127.9 * F in kitchen sink exceeding regulatory range and 109.4 *F in master bathroom within regulatory range. Fire and carbon monoxide detectors in working order and fire extinguisher purchase receipt from 9/15/2020. Cleaning supplies in locked cabinet, observed arm and hammer, Lysol and Clorox sprays, Kirkland brand detergent. Staff observed with surgical or cloth masks on residents observed not wearing masks in common areas.

Observed a second living room not on facility sketch, included bed without any linens, a night stand and a TV. Licensee and designee stated the bed was used it was for used for dumping and folding laundry not residents.

Garage, sheds and backyard observed with several extra beds, wheel chairs, patio umbrella and two recliners. Licensee stated it will be removed tomorrow 2/12/21. Observed residents personal care items in shower, loofahs and personal soaps.

Comp III completed with Licensee applicant Nataley Martinez

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE	FACILITY NUMBER: 502700876
	VISIT DATE: 02/11/2021

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Continued from 809 C. Page 3 of 3

The following are required before facility can be approved for licensure:

I. Replace all trash cans with touchless, covered trash cans.

II. Water temperature correction for all faucets to be within regulatory range.
III. Chair and bed spacing need to be 6 feet apart or head to toe orientation per COVID precautions.
IV. Replace not working light bulbs
V. Carpet cleaned or replaced
VI. Broken cabinets in restroom and kitchen repaired or replaced
VII. Screen door off of kitchen repair or replace
VIII. Screen at window repair or replace
IX. Fence and exposed nails repair or replace
X. Gutters repair or replace
XI. Remove all extra furniture, bed, recliners and umbrellas
XII. Updated facility sketch to be submitted to include second living space
XIII. Secure residents personal care items not left in shower when not in use

An exit interview was conducted with Nataley and Ryta via conference call with LPA's at 5:32pm. During exit interview LPA's requested notification when the above requirements have been met and the facility is ready for re-evaluation for licensure. At this time the facility is not approved to be licensed. A follow up report documenting corrections will be created once corrections are received and application approved.

A copy of this report was provided to Nataley and Ryta via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 and appeal rights were received. Nataley and Ryta are to print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov and Eric Stone eric.stone@dss.ca.gov signed and returned by 2/13/21.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

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