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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600773
Report Date: 02/24/2022
Date Signed: 02/24/2022 10:14:20 AM

Document Has Been Signed on 02/24/2022 10:14 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:QUALITY CARE HOMEFACILITY NUMBER:
198600773
ADMINISTRATOR:FLORESITA P LIMFACILITY TYPE:
735
ADDRESS:990 MURCHISON AVENUETELEPHONE:
(909) 620-7655
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Floresita Lim, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Floresita Lim and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, observed food supply, and reviewed staff records. The facility cares for developmentally disable adults and is vendorized by San Gabriel/Pomona Regional Center as a Level 3 home.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The client bathrooms have the required grabs bars and non-skid mat. The hot water was 114.4 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is additional food in the garage freezer. All the appliances are clean and seem to be operating properly. The common areas include the front living room, back living room and dining area. These areas are clean and have the required furniture. There is a sanitizer station at the entrance of the home along with PPEs. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA reviewed 5 client records to confirm emergency contact is updated and clients have health screenings on file. 3 staff records were reviewed to confirm health screenings, infection control training and fingerprint clearances. Staff did not have proof of infection control training on file. LPA reviewed 5 clients' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed during the visit is documented on 809D. Exit interview held. A copy of the report and appeal rights were provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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Document Has Been Signed on 02/24/2022 10:14 AM - It Cannot Be Edited


Created By: Tony Vasallo On 02/24/2022 at 10:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUALITY CARE HOME
FACILITY NUMBER: 198600773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 3 out of 3 staff records which poses a potential health, safety or personal rights risk to persons in care. Facility did not have proof of infection prevention, symptoms, transmission and PPE use training.
POC Due Date: 03/10/2022
Plan of Correction
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By 3/10/22, facility will submit proof of training for all 3 staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
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