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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601281
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:23:23 PM


Document Has Been Signed on 09/07/2022 01:23 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:QCARE RESIDENTIAL FACILITY IIFACILITY NUMBER:
075601281
ADMINISTRATOR:CUNANAN, JOAQUINFACILITY TYPE:
740
ADDRESS:4363 FAIRWOOD DRIVETELEPHONE:
(925) 676-8727
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 3DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Analyn Bravante, Caregiver TIME COMPLETED:
01:30 PM
NARRATIVE
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On 09/07/2022 at 11:25 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Analyn Bravante and explained the purpose of the visit. Administrator arrived at approximately 12:05 pm.

Upon entry, LPA temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation.

The following deficiencies were observed during the visit:

-At 11:51 am, LPA observed 2 small bedrooms located in the garage.
-At 11:54 am, LPA observed a chair, wood, cabinet, seat cushion, table leaf, toilet top, CD holder, ladder, shovel, rake, small oxygen tank located on the side yard.
-At 11:56 am, LPA observed chairs, washer and dryer, bed frames, night stand, shower chair, mattresses located behind a shed.

Continued on LIC809C.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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 4


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: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281
VISIT DATE: 09/07/2022
NARRATIVE
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Continued from LIC809

-The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/07/2022 01:23 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: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)

(a) The facility shall be clean, safe, sanitary 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
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Based on observation, the licensee did not comply with the section cited above by having chairs, wood, cabinets, toilet top, CD holder, ladder, table leaf, shovel, rake, oxygen tank, bed frames, washer and dryer and night stand which poses a potential health, safety risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will remove building materials, chairs, wood, cabinets, toilet top, CD holder, ladder, table leaf, shovel, rake, oxygen tank, bed frames, washer and dryer and night stand from the backyard into storage and/or dumpster and will provide pictures to CCL no later than the POC date.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by alliterating an existing building which poses a potential health and safety or personal risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will submit approved permit from the local county department along with a new facility sketch to CCL no later than the POC date.

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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4