Community Care Licensing

NARRATIVE

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On 08/02/23 around 09:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Maria Riformo, Administrator (ADM) arrived about 10 minutes later. ADM currently holds a standard certificate (#6006016740). The facility’s fire clearance was approved for six (6), four (4) may be non-ambulatory residents. Upon entry, LPA observed one (1) resident coming out of the bathroom and the television was on in the living room. LPA and ADM toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE centrally stored in the facility and accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 107.8 degrees Fahrenheit (F) and the facility's temperature was 73 degrees (F). Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Lisha Holmes TELEPHONE: 510-286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023

Document Has Been Signed on 08/02/2023 04:10 PM - It Cannot Be Edited

FACILITY NAME: HM LOVE & CARE HOME	FACILITY NUMBER: 075601208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

Type A

Section Cited

CCR

87355(d)(3)

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review, the licensee did not comply with the section cited above in 1 out of 3 persons, the Care Staff was not associated to the facility and did not have criminal record clearance which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	Care staff was escorted out of the facility by Co-Administrator on 08/02/23 around 10:30 AM.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Lisha Holmes TELEPHONE: 510-286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023

Document Has Been Signed on 08/02/2023 04:10 PM - It Cannot Be Edited

FACILITY NAME: HM LOVE & CARE HOME	FACILITY NUMBER: 075601208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

Type B

Section Cited

CCR

87303(a)

The facility shall be...safe...and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 12 lower kitchen drawers did not have a panle and was in direpair which poses a safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licensee to review regulation, inform staff, self-certify, and provide a photo to CCLD on or before 08/16/23.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Lisha Holmes TELEPHONE: 510-286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023

FACILITY NAME: HM LOVE & CARE HOME	FACILITY NUMBER: 075601208
	VISIT DATE: 08/02/2023