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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600533
Report Date: 10/14/2024
Date Signed: 11/06/2024 11:47:37 AM

Document Has Been Signed on 11/06/2024 11:47 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QUALITY LIVINGFACILITY NUMBER:
075600533
ADMINISTRATOR/
DIRECTOR:		ISVORANU, MARY V.FACILITY TYPE:
735
ADDRESS:3154 HACIENDA DRIVETELEPHONE:
(925) 680-7782
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Mary Isvoranu, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 10/14/2024 at 12:00 PM, Licensing Program Analysts (LPAs) D. Doidge and J. Clancy-Czuleger arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Mary Isvoranu, Licensee.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication cabinet. Smoke detectors and Carbon monoxide detectors were observed in working condition. Fire extinguishers were observed to be full and last serviced on 09/05/2024. Temperature in the facility was measured at 75.4 degrees Fahrenheit at 10:51 AM. Water temperature is 105 degrees Fahrenheit.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.


One week of nonperishable and 2 days of perishable food supplies were available.

The following deficiency was observed: one Staff records was missing Health Screening report.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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 11/06/2024 11:47 AM - It Cannot Be Edited


Created By: David Doidge On 10/14/2024 at 02:14 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: QUALITY LIVING
FACILITY NUMBER: 075600533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Licensee agrees to have staff missing TB test take test and update Health Screening report. Proof of correction will be sent to CCLD by POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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