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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209146
Report Date: 09/27/2023
Date Signed: 09/27/2023 08:10:16 PM


Document Has Been Signed on 09/27/2023 08:10 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: 29DATE:
09/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Staff Tracie WhiteTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to investigate 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 Tracie White. Administrator arrived at the facility to finish the visit.

During the tour of the facility, it was found R2 has a restricted health care condition. R2 was observed in the dining room when LPA observed the restricted health condition. Facility staff does not have access to resident records. Facility staff was unable to provide the name of R2. Facility staff does not know who is caring for the restricted health care condition.

During the tour, LPA observed pre dosed medications in small manilla envelopes. Facility staff that are not medication technicians are administering the medications however they are not the staff that are logging the medications have been given. Staff that are not present/administering medications are logging medications were given to residents.


LPA was unable to review resident or staff records at the facility. Administrator was not able to provide staff training for restricted health care plan or a copy of the care plan for R2.

A copy of this report was provided to Administrator along with appeal rights and plan of correction.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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 09/27/2023 08:10 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: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2023
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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Plan of Correction POC Licensee agrees to submit a request to retain residents with restricted health conditions and plans of care by POC due date.
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This requirement was not met as evidenced by Licensee did not submit an exception for R2's restricted health care plan which poses and immediate health safety and/or personal rights risk to residents in care.
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Type A
09/28/2023
Section Cited
CCR87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Plan of Correction: Licensee agrees to submit a written understanding of this regulation by POC due date 09/28/23
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This requirement was not met as evidenced by Licensee did not store all residents medications in original container. LPA observed all resident medcations in individual small manilla envelopes with residents names which poses an immediate health and 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: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2