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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601282
Report Date: 09/07/2022
Date Signed: 09/12/2022 11:01:12 AM


Document Has Been Signed on 09/12/2022 11:01 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:QCARE RESIDENTIAL FACILITY IIIFACILITY NUMBER:
075601282
ADMINISTRATOR:CUNANAN, JOAQUINFACILITY TYPE:
740
ADDRESS:4369 FAIRWOOD DRIVETELEPHONE:
(925) 682-0111
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Celia Manansala, CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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On 09/07/2022 at 1:38 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Celia Manansala and explained the purpose of the visit. Administrator arrived at approximately 1:43 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 1:47 pm, LPA observed sharps drawer with knives located in the kitchen lock is broken.
-At 1:49 pm, LPA observed scissors located in the living room on a bookshelf.
-At 1:50 pm, LPA observed the medicine cabinet had the keys hanging in the door and the door is broken.
-At 1:52 pm, LPA observed 2 small bedrooms located in the garage that are not on the facility sketch.
-At 1:54 pm, LPA observed chairs, lamp, rake, shovel, hoe, pick, pitch fork, lawn mower, pressure washer, mattresses, and stove top.
-At 1:56 pm, LPA observed a common fence on the right side of the house leaning and held up by wood planks.

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 5


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 III
FACILITY NUMBER: 075601282
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 5
Document Has Been Signed on 09/12/2022 11:01 AM - 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 III
FACILITY NUMBER: 075601282

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 a broken drawer with knives, scissors accessible located in a bookshelf and the keys to the medication closet hanging in the door of the closet and the knob broken which makes the medication accessible to residents in care which poses an immediate health and safety to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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Administrator agreed to repair the kitchen sharps drawer and repair or replace the door know to the medication closet and email photos to CCLD no later then the 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 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 5


Document Has Been Signed on 09/12/2022 11:01 AM - 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 III
FACILITY NUMBER: 075601282

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 dresser, weed eater, chair, lamp, rake, shovel, hoe, pick, pitch fork lawn mower, pressure washer, mattress, stove top and leaning fence which poses a potential health and safety risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator agreed to lock tools weed eater, rake, shovel, hoe, pick, pitch fork and lawn mower in the locked shed and remove the dresser, chair, lamp, mattress, stove top and repair fence by POC date and email photo copies to CCLD no later then POC date.
Type B
Section Cited
CCR
87305(a)
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 alternating the existing building which poses a potential health and safety 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: 5 of 5