<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700876
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:37:01 PM

Document Has Been Signed on 12/13/2022 12:37 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, 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:
12/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Emily RamirezTIME COMPLETED:
12:40 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
On 12/13/22 at approximately 10:20am Licensing Program Analyst (LPA) Jensen arrived at the facility to conduct a health and safety case management. LPA Jensen met with care provider and explained the purpose of today's visit. LPA Jensen called the Licensee and the phone number is disconnected. LPA Jensen contacted the Administrator by telephone and explained the purpose of today's visit. The Administrator was not at the facility as she was required to attend to personal matters.

LPA Jensen toured the facility and observed 6 residents in care. The thermostat was set at 74 degrees which falls within the required regulatory range of 68-85 degrees. Medications were observed to be locked and inaccessible to residents in care. The facility was observed to be free of odor and to contain all required furniture and linens and bedding. LPA Jensen toured the grounds and the grounds were observed to be free of debris and all paths were free of obstruction.

LPA Jensen observed several food items to be expired. LPA Jensen also observed several food items to be stored without a label. The refrigerator produce drawers were observed to have liquid pooling from decomposing produce. The expired food included but was not limited to: 2 tubs of macaroni salad, 4 packages of bread, peanut butter, cheese sauce, bell peppers, spinach, cucumbers and carrots. Staff discarded all expired food, unlabeled food and cleaned the refrigerator in the presence of LPA Jensen. The facility did not have a supply of food sufficient to prepare the menu items listed and posted on the facility menu. The facility also did not have a 7 day supply of non-perishable food on hand.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights was given to the care provider.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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 2
Document Has Been Signed on 12/13/2022 12:37 PM - It Cannot Be Edited


Created By: Maja Jensen On 12/13/2022 at 12:03 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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
87555(a)

1
2
3
4
5
6
7
87555 General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to have a one week supply of groceries delivered to the facility today. Licensee agrees to order lunch for the residents and have it delivered today. Licensee agrees to email food receipts to maja.jensen@dss.ca.gov on a weekly basis for 4 weeks beginning 12/14/22.
8
9
10
11
12
13
14
Based on LPA's observation of expired food itens and improperly stored items. This poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
12/20/2022
Section Cited
CCR87555(b)(26)

1
2
3
4
5
6
7
87555 General Food Service Requirements
...
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to have a one week supply of groceries delivered to the facility today. Licensee agrees to order lunch for the residents and have it delivered today. Licensee agrees to email food receipts to maja.jensen@dss.ca.gov on a weekly basis for 4 weeks beginning 12/14/22.
8
9
10
11
12
13
14
Based on LPA Jensen's observation of a non-perishable food supply that did not meet the minimum requirement or one week's supply to be mainatined on site. This poses a potential risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2