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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601208
Report Date: 09/02/2026
Date Signed: 09/02/2026 07:24:54 PM

Document Has Been Signed on 09/02/2026 07:24 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/
DIRECTOR:		RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:508 KAYANN COURTTELEPHONE:
(510) 222-1406
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 4DATE:
09/02/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Maria Riformo/Licensee-AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:25 PM
NARRATIVE
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On this day, 9/02/26, Licensing Program Analyst (LPA) Delmundo conducted Proof of Correction (POC) visit.

On 5/05/26, LPA conducted investigation of a complaint (15-AS-20260427120706) and issued citations for deficiency section #s 87244(a)(1) and 1569.655(a) with POCs to be submitted by 5/19/26. On that same day, LPA also issued citation under case management for section # 87307(a) with POC due by 5/20/26. POCs were not submitted.

Deficiencies are re-cited and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof corrections were discussed with LIC-ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
Bennett Fong
Alicia Delmundo
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/02/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/02/2026 at 06:41 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87224(a)(1)

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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident..... (1) Nonpayment of the rate for basic services within ten days of the due date.
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Licensee-administrator to read the Regulations and self-certify full understanding. Proof to be submitted by 9/16/26.
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-This requirement is not met as evidence by:
-Based on interviews and record review, the licensee did not comply with the section above in incorporating eviction for non-payment to the rate increase notification which poses a potential rights risks to persons in care.
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Type B
09/16/2026
Section Cited
HSC1569.655(a)

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§1569.655 Increase in fee rates for elderly residents; 90 days’ written notice...
(a) .... the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’representatives setting forth the amount of the increase and the reason or reasons for the increase, including a ......
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Licensee-administrator to correct and rewrite the notification. Copy to be submitted by 9/16/26.
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....description of the additional costs....
-This requirement is not met as evidence by:
-Based on interviews and record review, the licensee did not comply with the section above in giving a written notification for increase to R1 16 days after the date on the letter and does not include description of the addtional costs for increase.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/02/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/02/2026 at 06:47 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. ........

-This requirement is not met as evidenced by
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Corrected.

On this day, 9/02/26, LPA observed all of R1's personal belongings were removed from the dining table.
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-Based on observation and interview, the licensee did not comply with the section above in having R1's personal and confidential documents and medications stacked in the dining table which pose a potential personal rights risks 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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