157209146-4-3-2024-24-AS-SPIY-D49KMP-20240412080150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209146
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:04:07 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
01/16/2024 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20240116151446

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: 43	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Staff Paula Maribel Brizuela		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff are not providing adequate food service for residents
Staff are not meeting resident's dietary needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. LPA explained the purpose of the visit. Staff Paula Maribel Brizuela advised the Administrator is currently out of the country.

LPA toured the facilty. LPA checked the food and took photos. LPA took photos of the menu. LPA requested staff training for kitchen staff. Facility could not provide staff training documents for food service. LPA interviewed staff. Facility does not have a 2 day pershiable and a 7 day non pershiable food supply. LPA took photos.

Facility is serving won ton soup and eggrolls with jello for lunch during visit. LPA oberved a small bowl of soup with 3 wontons in each bowl, 3 egg rolls and 2 small slices of oranges. The menu states liver an onions, mashed potatoes, sweet green peas, dinner rolls, cake and an alternative of roasted chicken. For dinner the menu states chili dog with cheese diced onions, french fries, pickle spear and cinnamon apple sauce. Facility is serving ground beef, boxed mashed potatoes and oranges.

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: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 24-AS-20240116151446

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: 04/03/2024

NARRATIVE

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Facility does not have qualified personnel creating the menu for residents. The menu is not being followed. Facility does not have the ingredients to cook what is on the menu. Facility does not have a menu for residents who require special diets. LPA found 5-7 pounds of hamburger meat not refrigerated that felt warm to touch and is planned to be served for dinner. Facility put warm meat back in freezer.

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.

Refer to 809 and 809D for additional deficiencies observed during visit.

A copy of the this report was provided to the Administrator with appeal rights and plan of correction.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20240116151446

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: 04/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/12/2024 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food	1 2 3 4 5 6 7	Plan of Correction Licensee agrees to provide a written statement of quality and quanity of food that will meet the needs of the residents. by POC due date 04/9/24. Facility staff took out an additional 6.82 pounds of hamburger meat during visit to serve for dinner and stated facility would add canned green beans to the meal.
	8 9 10 11 12 13 14	shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Licensee did not have a sufficient amout of meat planned to cook for dinner. Facility had 5 to 7 pounds of meat out for dinner for 43 residents which poses an immediate health safety and or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 04/09/2024 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. Licensee did not provide a modfied diet menu for residents R1 thru	1 2 3 4 5 6 7	Plan of Correction POC Licensee agrees to create and submit a menu from a licensed professional or qualified person to meet the needs of residents requiring a special diet by POC due date 4/9/24.
	8 9 10 11 12 13 14	R6 that require doctor order modified diets which poses a potential health safety and or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
01/16/2024 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20240116151446

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: 43	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Staff Paula Maribel Brizuela		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not prevent pests in the facility

INVESTIGATION FINDINGS:

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Unfounded

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: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4