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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209146
Report Date: 07/05/2023
Date Signed: 07/05/2023 01:02:47 PM


Document Has Been Signed on 07/05/2023 01:02 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
157209146
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2607 MT. VERNON AVENUETELEPHONE:
(661) 871-8133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 45DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Staff Baula Maribel BrizuelaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings on a complaint investigation, where other deficiencies were observed during the course of the investigation. LPA conducted a case management to address the deficiencies. LPA met with Staff Baula Maribel Brizuela. Administrator was not available for the visit. LPA spoke with Staff Oscar Chavez via telephone who assisted with the visit.

During the course of the Departments investigation, it was found the facility did not report R1's contagious diagnosis or R1's hospitalization's.

During the course of the Departments investigation, it was found the facility staff were not following R1's needs and service plan by not assisting R1 with showering.

During the course of the Departments investigation, it was found R1's LIC602 physicians report was not properly filled out by not listing R1's diagnosis or listing the name of the primary physician.

Deficiencies were observed and were cited under Title 22, Division 6. See LIC 809D.

An exit interview was conducted with Staff. A copy of this report, plan of correction and appeal rights were provided.


SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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 3


Document Has Been Signed on 07/05/2023 01:02 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 157209146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
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Plan of Correction POC Licensee agrees to submit a written statement on how this regulation will be met in the future by POC due date 7/14/23.
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This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by: Licensee did not report communicable disease or hospitalizations for R1, which poses a potential health, safety, and/or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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