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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700876
Report Date: 12/14/2022
Date Signed: 12/16/2022 10:50:57 AM

Document Has Been Signed on 12/16/2022 10:50 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A LOVING PLACEFACILITY NUMBER:
502700876
ADMINISTRATOR:MARTHA ARREGUINFACILITY TYPE:
740
ADDRESS:2800 CATALA WAYTELEPHONE:
(714) 948-0381
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Martha ArreguinTIME COMPLETED:
06:00 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 12/14/2022 by Licensing Program Analyst (LPA) Charlie Yang and Regional Manager (RM) Stephenie Doub who were met by the facility designated Administrator Martha Arreguin. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 6 residents.
The purpose of this visit was to make sure that there was adequate staffing and supervision being provided to the residents at all times. It was learned that the sole facility staff person on duty had to be taken to the emergency room, via ambulance, and that the facility residents were left without any adequate care and supervision at this time.
Upon arrival to this facility, LPA Charlie Yang and RM Stephenie Doub were met at the door by the facility designated Administrator. It was learned that the facility staff person, S1, was taken to the emergency room and Modesto Fire, and its personnel, had to standby until the facility designated Administrator Martha Arreguin arrived at this facility before departing.
A brief tour of this facility was conducted by RM Stephenie Doub.
A review of the facility resident files was conducted by LPA Charlie Yang and the following LIC 858s.
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 rules and regulations, Health and Safety Codes.

A civil penalty in the amount of $1000 was issued at this time on the following (2) LIC 421(IM).

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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Document Has Been Signed on 12/16/2022 10:50 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/14/2022 at 05:03 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE
FACILITY NUMBER: 502700876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited
CCR
87202(a)(2)

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Fire Clearance
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and
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Facility designated Administrator stated that a proper 30-day eviction notice will be served unto the resident, and their responsible parties, before searching for a suitable licensed care facility to accept and retain residents with a bedridden diagnosis. A statement of correction, along with copies of the eviction notice and possible relocation sites, will be
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obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons
This facility was deficient as evidenced by accepting and retaining a bedridden resident without the proper notification unto CCL and proper request/approval for the proper bedridden fire clearance.
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completed and submitted into CCL by the due date of 12/15/2022.
Type A
12/15/2022
Section Cited
CCR87405(a)

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Administrator-Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention
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Facility designated Administrator stated that a copy of the updated administrator renewal packet will be copied and sent into CCL for review by this LPA. After discussion with the facility Licensee Nataley Martinez, a plan to hire an additional certified Administrator will be implemented. A statement of correction, along with all requested forms and documents, will
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to the management and administration of the facility as specified in this section.
This facility was deficient as evidenced that the sole facility Administrator allowed her certificate to lapse and does not currently have a valid Administrator certificate at this time. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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be completed and submitted into CCL for review by this LPA by the due date of 12/15/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2022 10:50 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/14/2022 at 05:18 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A LOVING PLACE
FACILITY NUMBER: 502700876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited
CCR
87411(a)

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Personnel Requirements-General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This facility was observed to be deficient as evidenced by the lack of facility personnel being present at this facility for an undisclosed
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Facility designated Administrator stated that additional staff will be recruited and hired through social media and word of mouth. A plan of action will be devised and implemented after discussion with the facility Licensee Nataley Martinez. A statement of correction, along with outlined implementation plan, will be completed and submitted into CCL by the due
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amount of time. This posed an immediate threat to the Health, Safety, and Personal Rights to the residents in care.
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date of 12/15/2022.

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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