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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601282
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:07:56 PM


Document Has Been Signed on 04/18/2024 02:07 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 IIIFACILITY NUMBER:
075601282
ADMINISTRATOR:CUNANAN, JOAQUINFACILITY TYPE:
740
ADDRESS:4369 FAIRWOOD DRIVETELEPHONE:
(925) 682-0111
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marilyn 'Lyn' Ramirez/StaffTIME COMPLETED:
02:15 PM
NARRATIVE
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On this day, April 18, 2024, while at the facility investigating a complaint (Complaint Control # 15-AS-20240410121644), Licensing Program Analyst (LPA) Delmundo learned that staff (S1) who is fingerprint cleared and associated to licensee's other facility is not associated to this facility, QCare Residential Facility III.

LPA also observed resident's (R1) record is not complete. There's no LIC602A Physician's Report and Pre-placement Appraisal on file. This was discussed over the phone with Joaquin Cunanan, administrator, who stated the documents were at licensee's other facility. The administrator asked Marilyn Ramirez, staff, to locate the documents but was unsuccessful. LPA also discussed about S1 not associated to this facility.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with the administrator over the phone. Administrator stated he can not come to the facility, and authorized Marilyn Ramirez to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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 04/18/2024 02:07 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 III
FACILITY NUMBER: 075601282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review.... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
-This requirement is not met as evidenced by:
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Administrator to have the staff associated, and submit proof by 5/02/24.
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-Based on record review and Guardian Portal look-up, the licensee did not comply with the section above for not having S1 associated to this facility which poses a potential safety and/or personal right risks to persons in care.
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Type B
05/02/2024
Section Cited
CCR87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Administrator to complete the resident's file, and submit self-certification by 5/02/24.
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-This requirement is not met as evidenced by:

-Based on record review and interview, the licensee did not comply with the section above for not having R1's documents readily avalable for review.
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2