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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209146
Report Date: 04/22/2024
Date Signed: 04/22/2024 11:21:13 AM


Document Has Been Signed on 04/22/2024 11:21 AM - 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: 41DATE:
04/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Staff Paula Maribel BrizuelaTIME COMPLETED:
11:30 AM
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
Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. During the course of the investigation, a Case Management was conducted to address additional deficiencies. LPA contacted Administrator Ria Loria via telephone who gave permission for Staff Paula Maribel Brizuela to sign for the report.


During the course of the investigation, LPA reviewed S1's file. S1 only had an LIC 501 in the staff file. LPA also observed no activities or Activities Director for residents at the facility.

A copy of the this report was provided to the Administrator 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: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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 04/22/2024 11:21 AM - 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: 04/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
87412(a)

1
2
3
4
5
6
7

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
1
2
3
4
5
6
7
Plan of Correction Plan of Correction Licensee agrees to submit a copy of S1's entire file including all Licensing requirements by POC due date 4/26/24.
8
9
10
11
12
13
14
This requirement was not met as evidenced by Licensee did not have a complete personnel file for S1 which poses a potential health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
05/17/2024
Section Cited
CCR87219(f)

1
2
3
4
5
6
7
87219 Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The
1
2
3
4
5
6
7
Plan of Correction Licensee agrees to hire a full time activities staff designated to create activities for residents and submit the staff hired information and a copy of a planned activities calendar by POC due date 5/17/24.
8
9
10
11
12
13
14
responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement was not met as evidenced by Licensee does not have a full time staff for activities or planned activities for residents in care which poses an immediate 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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2