<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200317
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:00:50 PM

Document Has Been Signed on 04/20/2023 03:00 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Belinda Conyers, Administrator TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/20/2023 at 1:35 PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management visit. CCL received a Special incident report (SIR) on 4/16/2023, regarding C1 took wrong medications.

Administrator self reported the incident to CCL. Staff (S4) left medicine cup with F1’s medication on the dining room table. C1 grabbed the medications and took it. During the course of interview and records review, C1 ingested at least seven psychotropic medications.

Administrator took C1 to emergency room (ER) on the same day. Poison control was contacted while C1 was at the ER. C1 stayed at the hospital for couple of hours for observation. Based on records review, C1 had tachycardia as side effects of the medications but no other side effects.

During the visit, LPA attempted to interview C1, however C1 was non-verbal and could not answer LPA questions. LPA observed that C1, appeared to be comfortable at the facility.

Administrator contacted their contract pharmacy to conduct staff medication training. A medication training was conducted on 4/17/2023.

The above 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. Appeal Rights and a copy of this report 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
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 2
Document Has Been Signed on 04/20/2023 03:00 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2023 at 02:12 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2023
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
(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:
1
2
3
4
5
6
7
Administrator contacted pharmacy to conduct medication training for staff.
8
9
10
11
12
13
14
Based on interview and records review, licensee did not comply with the section cited above, staff failed to locked medications, C1 ingested F1's medication and was hospitalized for couple of hours, which posed an immediate health & safety risk to clients in care.
8
9
10
11
12
13
14
Cleared during the visit.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 2 of 2