075601282-4-18-2024-15-AS-KHOS-D4MGMQ-20240424052815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601282
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:06:57 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240410121644

FACILITY NAME:	QCARE RESIDENTIAL FACILITY III		FACILITY NUMBER:	075601282
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4369 FAIRWOOD DRIVE		TELEPHONE:	(925) 682-0111
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 4	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marilyn 'Lyn' Ramirez/Staff		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Due to staff adding an additional lock on the front door, residents are locked in at night.

INVESTIGATION FINDINGS:

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At 11:30 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA was granted entry by staff, Celia Manansala, and informed the reason for visit. LPA called and spoke over the phone with Joaquin Cunanan, administrator, who stated he can not come to the facility and authorized Marilyn 'Lyn' Ramirez to sign and receive this report.

LPA checked the inside of the front door and observed a lock located close to the top of the door. The lock was observed with a key hole. LPA inteviewed the administrator and staff (S1 and S2) who all stated that the lock was installed to prevent resident from leaving the facility at night.

Based on observation and interviews, the preponderance of evidence is met, therefore, the allegation is substantiated.

.....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240410121644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/18/2024

NARRATIVE

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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed for fire safety violation and will continue for $100.00/day until corrected.

Deficiency, plan and proof of correction, and civil penalty were discussed with the administrator over the phone.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240410121644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 04/19/2024 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to do the following, and submit proof by 4/19/24: 1. Remove the lock and submit picture. 2. Ensure there's an awake/night staff and submit LIC500 Personnel Report. 3. In-service the staff and submit copy of in-service training with attendees signatures,
	8 9 10 11 12 13 14	-Based on observation and interviews, the licensee did not comply with the section above in installing lock on the front door which poses an immediate safety and/or personal rights risks to persons in care. Civil penalty is assessed.	8 9 10 11 12 13 14	A $500.00 civil penalty is assessed.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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