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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:38:12 PM


Document Has Been Signed on 09/05/2023 12:38 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HM LOVE & CARE HOMEFACILITY NUMBER:
075601208
ADMINISTRATOR:RIFORMO, HAILEY R.FACILITY TYPE:
740
ADDRESS:508 KAYANN COURTTELEPHONE:
(510) 222-1406
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 2DATE:
09/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maria Rirformo, LicenseeTIME COMPLETED:
12:45 PM
NARRATIVE
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On 9/5/2023 at 12:10pm, Licensing Program Analysts (LPA) L. Hall and L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Maria Riformo, Licensee and explained the reason for the visit.

While LPA L. Hall was conducting a complaint investigation (15-AS-20230901131403) on 9/5/2023. During visit LPAs were informed that the file for R1 was not available on the premises for review.

The deficiency was observed (see LIC809D) and cited per Title 22 California Code of Regulations. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiency within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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 09/05/2023 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: HM LOVE & CARE HOME
FACILITY NUMBER: 075601208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2023
Section Cited
CCR
87506(d)

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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
This requirement was not met as evidence by:
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Licensee agreed to review regulation 87506 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having R1's file available for review on premises, which poses a potential health and safety risk to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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