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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200317
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:44:44 PM

Document Has Been Signed on 04/20/2023 02:44 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:QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
079200317
ADMINISTRATOR:BELINDA CONYERSFACILITY TYPE:
735
ADDRESS:17 BOBWHITE CT.TELEPHONE:
(925) 679-0515
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 2DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:BELINDA CONYERS, Administrator TIME COMPLETED:
01:30 PM
NARRATIVE
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On 4/20/2023 at around 10:00AM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct annual required inspection and greeted by Administrator Belinda Conyers. Facility has census of 2. LPA observed 3 staff.

LPA observed Administrator's daughter (F1) residing at facility who is an RCEB client. Daughter is fingerprint cleared and associated to facility.

LPA toured the entire premises with staff (s3), including but not limited to indoors and outdoors. Smoke detectors and carbon monoxide detectors were observed operational. The facility was observed to be clean and odor free. LPA observed fire extinguisher located at the kitchen area with receipt date of June 2022.

There was sufficient supply of perishable and nonperishable foods observed. Freezer temperature was observed at zero (0) degrees Fahrenheit. Refrigerator temperature measured at 40 degrees Fahrenheit. First aid kit was complete. Vehicle insurance and registration were verified as current.

LPA reviewed medication and Medication Administration Record (MAR) with S3 facility. P&I money and documents was reviewed.



LPA interviewed 2 staff. LPA attempted to interview clients in care, however clients are non-verbal. Clients appeared to be comfortable, has clean clothes and no odors noted. At around 11am, LPA reviewed 2 clients files and 3 staff files.

...Continues to LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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: QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 079200317
VISIT DATE: 04/20/2023
NARRATIVE
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The following deficiency were observed:
At around 10:15AM, LPA observed swimming pool gate was unlocked. (Corrected by S3, as soon as it was observed)
LPA observed that S3's first aid certificate was expired.

A $500.00 Civil penalty was assessed during today's visit.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/20/2023 02:44 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2023 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 079200317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence.

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 in, licensee failed to secure or lock the swimming pool gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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Clear and corrected during the visit.
Staff (s3) locked the gate as soon as it was observed.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/20/2023 02:44 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2023 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 079200317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 in licensee failed to renew S3's first aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator will send S3 for first aid/cpr training. Administrator will send a proof of training to CCL by 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
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