157209146-6-19-2024-24-AS-SDOE-D6E8AC-20240619222032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209146
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:21:01 PM

Document Has Been Signed on 06/19/2024 10:21 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 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: 47	DATE:	06/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Nancy Cudal and LicenseeRepresentative Kristine Juarez		TIME COMPLETED:	10:45 PM

NARRATIVE

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Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's were granted entry by Staff Krizia Adajar. S LPA's met with Administrator Nancy Cudal. Licensee Representative Kristine Juarez responded to the facility to assist with the visit.

LPAs toured the facility inside and out. LPAs observed adequate food supply. When entering the facility there was an urine odor. Carbon monoxide detector were tested and are in working order. Facility has pull station fire alarm with sprinkler system. Fire extinguishers were serviced 2/29/24, LPAs observed one extinguisher to not have charge. Water temperature in R3 (128.1) & R5 (139.9) were over the allowed temperature.

LPAs observed the following deficiencies:

Sample of resident files were reviewed- R3's physician report was not complete and was missing DX. Resident files did not have PRN orders from physician, no plan of care for residents with restricted. LPAs observed hospice records which were not complete.

LPAs observed room 38 to have buildup in the shower. LPAs observed broken window, screens missing from windows, and screen torn. LPAs observed ice machine to have mold, on the side of the facility was broken furniture and other items.

Sample of staff files were reviewed and LPAs observed staff training to not be current or documented properly. Licensee did not have documentation for staff training for resident on hospice.

LPA observed a sample of resident's medication which were not recorded on centrally stored log and were not stored properly (R1). R1 did not receive medication from 11/2023 through 4/2024, facility does not have document records for this time period.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R3 & R5 water temperatures were above the allowed limit. R3 was 128.1 and R5 was 139.9
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee will correct water temperature to meet regulation listed above. Verification will be provided to LPA.

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Staff listed in the facility as the Administrator was not associated to the facility. Administrator was working in the facility for 2 months before being properly associated to the facility.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Staff will be associated to the facility. POC cleared during visit, staff associated during visit.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1 had not received insulin medication from November 2023 to April 2024.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a medication training for all medication technicians and submit a date training will be complete by POC due date 06/20/24.

Type A

Section Cited

CCR

87465(a)(5)

Incidental Medical and Dental Care Services

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Interviewees (staff and residents) stated glucose testing is conducted by staff. R2 & R3's physician reports state the residents cannot administer self injection or conduct own glucose testing.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update LIC 602's for R2 and R3 stating residents can administer their own injections and gluclose testing by POC due date 06/20/24

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Broken window, screens torn, mold in ice maker, trash and misc. items along the side of the facility (pictures). Room 38's shower had mildew buildup (picture). Sliding door to courtyard does not open and close properly.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit photos of items listed showing items are fixed and cleaned by POC due date 07/12/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. After conducting interviews with staff it was stated Administrator assists with MedTech and Caregiver duties when there is not enough staff.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of LIC500 staff schedule showing enough staff to complete all duties by POC due date 06/20/24

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to document the number of hours completed for training.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct staff training to meet this regulation and submit to licensing by POC due date 07/19/24.

Type B

Section Cited

HSC

1569.696(a)(1)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to document the number of hours completed for training.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct staff training to meet this regulation and submit to licensing by POC due date 07/19/24.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(1)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to document training completed by staff.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a staff training and submit training that meets this regulation by POC due date 07/12/24.

Type B

Section Cited

CCR

87555(b)(17)

General Food Service Requirements

(b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to have consultation services provided in the facility for food services and document consultation services.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit documentation that meets this regulation by POC due date 07/12/24.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed medication not being stored in original containers, and being placed in envelopes to be passed out in the evenings.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan on how this regulation will be met by POC due date 07/12/24

Type B

Section Cited

CCR

87465(c)(1)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Facility did not to have proper doctor's orders for resident's PRNs
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit in writing the understanding of this regulation and how it will be met by POC due date 07/12/24

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed resident files which did not have doctor's orders for PRN medication.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update files and create a procedure to meet this regulation. Licensee will submit plan by POC due date 07/19/24.

Type B

Section Cited

CCR

87506(b)(11)

Resident Records

(b) Each resident's record shall contain at least the following information: (11) The documentation required by Section 87611(a) for residents with an allowable health condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee did not to have required documentation for R1, R2, R3, R4, & R5
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update resident records and submit in writing how this regulation will be met by POC due date 07/19/24.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 9 of 13

Document Has Been Signed on 06/19/2024 10:21 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(13)

Resident Records

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee did not keep record of R1's medical needs when R1 refuses treatment.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit in writing the understanding of this regulation and how it will be met by POC due date 07/19/24.

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to maintain R3's physician report which did not have diagnosis listed.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update R3's physician report to show R3's diagnosis by POC due date 07/12/24.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 10 of 13

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
	VISIT DATE: 06/19/2024

NARRATIVE

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LPA's observed cleaning supplies to be in unlocked closets and outdoors on side of facility accessible to residents.
LPAs observed Administrator working in facility without being associated to the facility since May 2024.

LPA's observed R6 to have full bed rails with no physician's order. Hospice order states R6 is approved for half bed rails.

Deficiencies were cited on LIC809D and civil penalties were issued.

Exit interview was completed, a copy of this report LIC809, LIC809D, and appeal rights were provided to Licensee Representative Kristine Juarez.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 11 of 13

Document Has Been Signed on 06/19/2024 10:21 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above in Licensee had cleaning supplies in unlocked closets and outdoors on the outside yard of the facility accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to put a procedure in place to ensure cleaning supplies are locked. Licensee will conduct an inservice and submit by POC due date 6/20/24.

Type A

Section Cited

CCR

87608(a)(5)(B)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have a physician note for R6 to have full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to Hospice care plan that addresses doctor order for full bed rails by POC due date 06/20/24.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 12 of 13

Document Has Been Signed on 06/19/2024 10:21 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee did not have documentation to verify training was completed.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct staff traing to meet this regulation by POC due date 07/19/24. Civil Penalty issued.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 13 of 13