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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200257
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:34:46 PM


Document Has Been Signed on 10/09/2024 04:34 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:VANCOUVER HOME LLCFACILITY NUMBER:
079200257
ADMINISTRATOR:RAQUEL Q. HURSTFACILITY TYPE:
735
ADDRESS:2219 VANCOUVER WAYTELEPHONE:
(925) 822-3708
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 4DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jeremiah Quiba-Hurst, StaffTIME COMPLETED:
04:50 PM
NARRATIVE
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On 10/09/2024 at 1:15PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with staff, Jeremiah Quiba-Hurst.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 10/25/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105 degrees F in the hallway bathroom. There were adequate lights in each room. First Aid kit is complete. Indoor and outdoor passageways were free of obstruction. Last disaster drill was conducted on 08/22/2024.

LPAs reviewed 4 clients and 3 staff files starting at 1:40PM. LPAs reviewed client's P & I money with log. LPAs reviewed client's medications starting at 2:30PM. LPAs interviewed 1 clients and 2 staff during inspection.

At 2:10PM, LPAs observed unlocked cleaning supplies under the kitchen sink. Staff locked up the cleaning supplies during inspection.
At 2:15PM, LPAs observed unlocked medication in the kitchen drawer. Staff locked up the medication during inspection.
At 2:30PM, LPAs observed C1, C2, and C4 does not have current IPP or needs and services plan.
At 2:45PM, LPAs observed S1 does not have health screening on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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


Document Has Been Signed on 10/09/2024 04:34 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: VANCOUVER HOME LLC
FACILITY NUMBER: 079200257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 unlocked cleaning supplies under the kitchen sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Staff locked cleaning supplies during the inspection.

Deficiency cleared.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medication in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Staff locked medication during the inspection.

Deficiency cleared.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/09/2024 04:34 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: VANCOUVER HOME LLC
FACILITY NUMBER: 079200257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not having health screening completed for S1 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Administrator agrees to obtain health screening for S1 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current needs and service plan for clients which poses a potential health and safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Administrator agrees to obtain needs and service plan (LIC625) for C1, C2, and C4 and submit a copy to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4