157209146-10-18-2023-24-AS-SPIY-CXBUV7-20231106145437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209146
Report Date: 10/18/2023
Date Signed: 10/18/2023 12:33:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2023 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20231017081313

FACILITY NAME:	QUALITY CARE ASSISTED LIVING		FACILITY NUMBER:	157209146
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	2607 MT. VERNON AVENUE		TELEPHONE:	(661) 871-8133
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93306
CAPACITY:	54	CENSUS: 32	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Administrator Ria Loria		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident's dietary needs are not being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Ria Loria. LPA explained the purpose of the visit.

LPA toured the facility and took photos of the food and the menu. LPA observed lettuce and 1 bag carrots only. LPA did not observe any fresh fruit. Administrator could not provide staff training or qualified staff to create a special diet menu for LPA to view. Facility menu had an old facility name on it "Golden Castle".

LPA reviewed resident files. C1 did not have a diagnosis on C1's LIC602. C2 did not have a LIC 602 for this facility.

See 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20231017081313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/18/2023

NARRATIVE

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Based on the Departments interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D.

The Department found additional deficiencies during the course of the investigation, which will be addressed and cited on a separate 809 and 809D.

A copy of this report was provided to staff with plans of correction and appeal rights.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20231017081313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2023 Section Cited CCR 87555(b)(7)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Licensee did not	1 2 3 4 5 6 7	Plan of Correction POC Licensee agrees to provide a menu of a special diet to meet the needs of C2 by POC due date 11/3/23.
	8 9 10 11 12 13 14	provide a special diet for C2 who requires a special diet on LIC602. Based on observation and interview, C2 had cereal for breakfast and raviolis, peaches and potato chips for lunch which poses a potential health safety and or personal rights risk to clients in care.	8 9 10 11 12 13 14
	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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

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